Assessing health behavior change and comparing remote, hybrid and in-person implementation of a school-based health promotion and coaching program for adolescents from low-income communities.

To assess the impact of a school-based health intervention on adolescents' health knowledge, psychosocial assets and health behaviors, including comparisons of implementation mode: remote, hybrid or in-person. The Stanford Youth Diabetes Coaches Program, an 8-week, school-based health promotion and coaching skills program, was offered to adolescents (ages 14-18 years) from four low-income US communities. Mode of program implementation was remote, hybrid or in-person. Participants completed online pre- and postsurveys. Analysis included paired t-tests, linear regression and qualitative coding. From Fall 2020 to Fall 2021, 262 adolescents enrolled and 179 finished the program and completed pre- and postsurveys. Of the 179, 80% were female, with a mean age of 15.9 years; 22% were Asian; 8% were Black or African American; 25% were White; and 40% were Hispanic. About 115 participants were remote, 25 were hybrid and 39 were in-person. Across all participants, significant improvements (P < 0.01) were reported in health knowledge, psychosocial assets (self-esteem, self-efficacy and problem-solving) and health behaviors (physical activity, nutrition and stress reduction). After adjusting for sex and age, these improvements were roughly equivalent across the three modes of delivery. Participation was associated with significant improvements in adolescent health behaviors. Furthermore, remote mode of instruction was just as effective as in-person and hybrid modes.

Community Health Worker-led Implementation of the Stanford Youth Diabetes Coaching Program in Underserved Latinx Communities.

BACKGROUND: The Stanford Youth Diabetes Coaching Program (SYDCP) is an evidence-based program led by health care professionals to teach healthy youth who then coach family members with diabetes or other chronic conditions. This purpose of this study is to evaluate a Community Health Worker (CHW)-led implementation of the SYDCP for low-income Latinx students from underserved agricultural communities. METHOD: CHWs were trained and virtually led 10 training sessions virtually during the COVID-19 for Latinx students who were recruited from high schools in agricultural regions of Washington state. Feasibility measures include recruitment, retention, class attendance, and successful coaching of a family member or friend. Acceptability was measured by responses on the post-training survey. Effectiveness was evaluated by pre-post changes in measures used in prior studies of the SYDCP such as level of activation and diabetes knowledge. RESULTS: Thirty-four students were recruited, 28 completed the training and 23 returned both pre- and post-surveys. Over 80% of students attended 7 or more classes. All met with a family or friend and 74% met with them weekly. Approximately 80% of the students rated the program's usefulness as "very good" or "excellent." Pre-post increases in diabetes knowledge, nutrition-related behaviors, resilience, and activation were significant and similar to those observed in prior published studies of the SYDCP. CONCLUSIONS: Findings support the feasibility, acceptability, and effectiveness of a CHW-led implementation of the SYDCP in underserved Latinx communities using a virtual remote model.

Remote Implementation of a School-Based Health Promotion and Health Coaching Program in Low-Income Urban and Rural Sites: Program Impact during the COVID-19 Pandemic.

BACKGROUND: Adapting existing health programs for synchronous remote implementation has the potential to support vulnerable youth during the COVID 19 pandemic and beyond. METHODS: The Stanford Youth Diabetes Coaches Program (SYDCP), a school-based health promotion and coaching skills program, was adapted for remote implementation and offered to adolescents from low-income communities in the US: an urban site in San Jose, CA and rural sites in Lawrence County, MO, and Central Valley, CA. Participants completed online pre- and post- surveys. Analysis included paired T-tests, linear regression, and qualitative coding. RESULTS: Of 156 enrolled students, 100 completed pre- and post-surveys. Of those: 84% female; 40% Hispanic; 37% White; 28% Asian; 3% African American; 30% other race. With T-tests and regression models, the following measures showed statistically significant improvements after program participation: health knowledge, patient activation, health understanding and communication, consumption of fruits and vegetables, psychosocial assets of self-esteem, self-efficacy, problem-solving, and ability to reduce stress. Technology barriers were frequently reported at Lawrence County site. 96% participants reported making a lifestyle change after program participation. CONCLUSIONS: Remote implementation of health promotion programs for vulnerable youth in diverse settings has potential to support adoption of healthy behaviors, enhance patient activation levels, and improve psychosocial assets.

Effect of Stanford Youth Diabetes Coaches' Program on Youth and Adults in Diverse Communities.

The Stanford Youth Diabetes Coaches' Program (SYDCP) trains high school students to become diabetes coaches for friends and adult family members. The objective of this study was to assess effects of SYDCP participation on youth and adults from a rural and urban underserved high school community. We used a mixed-methods approach. Patient-Reported Outcomes Measurement Information System (PROMIS) measures for Pediatric Sense of Meaning and Purpose were measured in high school students. PROMIS Adult Global Health and Self-Efficacy was measured in coached adults. Paired t tests compared pre- and postintervention and 6-month follow-up scores. Thematic analysis was used to analyze focus group discussion of adults. Twenty-five students participated, 15 students coached adults with diabetes or prediabetes. Students' sense of meaning and purpose significantly improved postintervention compared to preintervention. Diet and physical activity behaviors improved. Adolescent-adult relationships mediated participation benefits. Our study showed SYDCP improved adolescents' sense of meaning and purpose. In addition, youth and adult relatedness led to improved health behaviors. These findings have important implications, as a sense of purpose and youth-adult connectedness are associated with health behaviors and psychological well-being. Further larger studies of health education programs that engage related youth-adult dyads and assess long-term behaviors and health outcomes are needed.

Increasing patient activation scores of vulnerable youth by partnering medical residency programs with public high schools.

OBJECTIVE: To assess whether participation in Stanford Youth Coaches Programs (SYCP) increases patient activation scores and patient activation levels for vulnerable youth from low income communities. METHODS: From 2016 to 18, seven high schools and four residency programs in California, Alabama, Kansas and Missouri participated in SYCPs. Enrolled youth participants completed online pre and post-participation surveys including the Patient Activation Measure (PAM®10). We used paired T-tests, chi square tests, and linear multivariate models to compare pre-and post-scores and levels. RESULTS: 143 participants completed pre- and post-participation surveys. The PAM®10 mean pre-test score was 64.5 and post-test was 69.37, with mean difference 4.89 (p=.002). Participants showed significant improvement in patient activation levels after participation. 60 % participants in lowest activation Level 1; 63 % in Level 2; and 32 % in Level 3 moved to a higher level of activation after participation; 46 % who started in Level 4 moved down to Level 3 after participation. CONCLUSION AND PRACTICE IMPLICATIONS: Participation in SYCPs has potential to significantly increase patient activation for vulnerable youth which could lead to lifelong improvements in health outcomes and decrease in healthcare costs.

Short-Term Medical Relief Trips to Help Vulnerable Populations in Latin America. Bringing Clarity to the Scene.

Non-profit organizations provide international medical relief trips to low/middle-income countries (LMIC) in order to provide healthcare to medically underserved areas. Short-term medical relief trips (STMRT) take a large amount of time and resources, and arouse concerns about their actual effectiveness. Here we develop a novel tool for consistently assessing how U.S. organizations provide primary care to Latin America through short-term medical relief trips. First, in Part 1, we create a "Best Practice" (BP) framework focused on the efficacy, sustainability, and long-term impact of the organizations based on a review of the last 27 years of available literature published in peer-reviewed journals. Second, in Part 2, out of 581 total medical relief organizations in the US, we identify the 19 organizations currently providing short-term primary care services to Spanish-speaking countries in Latin America. We use the BP framework to analyze the website content and secondary sources of these 19 organizations. We find that only three of the 19 organizations met 80% or more of the criteria defining BP according to the framework and four out of the 19 did not perform well in any of the framework's three aspects of efficacy, sustainability, and long-term impact. Because there exists no current standardized way of assessing the methods implemented and services offered by STMRT, we provide suggestions about using this novel framework as a self-assessment tool for STMRT organizations.

Increasing Screening Follow-Up for Vulnerable Children: A Partnership with School Nurses.

Approximately 20% of school-age children have a vision problem. Screening is an effective way to detect visual impairments, although only if adequate follow-up is available. Here, we evaluate the impact of hiring full-time nurses in four underserved schools on the likelihood of increasing follow-up for treatment after vision screening. First, we compared descriptive screening follow-up data from the intervention schools with that of five matched schools with part-time nurses in San Jose, California, from 2008 to 2012. The intervention schools had around 2800 low-income, minority children each year, and the five comparison schools had around 3445. Secondly, we conducted a qualitative analysis of open-ended survey responses from 129 teachers in the nine participating schools. In the final year, 96% of the students screened and referred for possible vision problems in schools with full-time nurses were followed up and examined by a health care provider. Yet, only 67% of students screened in comparison schools were examined. Teachers in schools with full-time nurses reported that follow-up of vision problems and getting glasses for students was the most beneficial activity performed by the nurses. School nurses can effectively increase medical care coordination and follow-up of vision screening in low-income communities.

Supporting At-Risk Youth and Their Families to Manage and Prevent Diabetes: Developing a National Partnership of Medical Residency Programs and High Schools.

BACKGROUND: The Stanford Youth Diabetes Coaches Program (SYDCP) is a school based health program in which Family Medicine residents train healthy at-risk adolescents to become diabetes self-management coaches for family members with diabetes. This study evaluates the impact of the SYDCP when disseminated to remote sites. Additionally, this study aims to assess perceived benefit of enhanced curriculum. METHODS: From 2012-2015, 10 high schools and one summer camp in the US and Canada and five residency programs were selected to participate. Physicians and other health providers implemented the SYDCP with racial/ethnic-minority students from low-income communities. Student coaches completed pre- and posttest surveys which included knowledge, health behavior, and psychosocial asset questions (i.e., worth and resilience), as well as open-ended feedback questions. T-test pre-post comparisons were used to determine differences in knowledge and psychosocial assets, and open and axial coding methods were used to analyze qualitative data. RESULTS: A total of 216 participating high school students completed both pre-and posttests, and 96 nonparticipating students also completed pre- and posttests. Student coaches improved from pre- to posttest significantly on knowledge (p<0.005 in 2012-13, 2014 camp, and 2014-15); worth (p<0.1 in 2014-15); problem solving (p<0.005 in 2014 camp and p<0.1 in 2014-15); and self-efficacy (p<0.05 in 2014 camp). Eighty-two percent of student coaches reported that they considered making a behavior change to improve their own health as a result of program participation. Qualitative feedback themes included acknowledgment of usefulness and relevance of the program, appreciation for physician instructors, knowledge gain, pride in helping family members, improved relationships and connectedness with family members, and lifestyle improvements. CONCLUSION: Overall, when disseminated, this program can increase health knowledge and some psychosocial assets of at-risk youth and holds promise to empower these youth with health literacy and encourage them to adopt healthy behaviors.

Service-Based Learning for Residents: A Success for Communities and Medical Education.

BACKGROUND AND OBJECTIVES: Community-based service-learning opportunities could support residents' acquisition of Accreditation Council for Graduate Medical Education (ACGME) competencies, but this concept has not been tested, and such programs are difficult to find. The objective of this work was to assess the value and the ACGME competency relevance of a service-learning program for residents that could be easily replicated nationally. METHODS: Forty-one family medicine residents from three training programs participated in the Stanford Youth Diabetes Coaches Program at six high schools in California and Georgia serving minority students of low socioeconomic status. Residents completed online surveys to provide qualitative feedback and assess the program's impact on their acquisition of residency program competencies and self-management support proficiencies, including prior use and planned use of action plans-a key self-management support strategy. RESULTS: Ninety-five percent of residents indicated that the program was a valuable experience that contributed to acquisition of residency program competencies, including interpersonal and communication skills and communication with teens. Compared with baseline, significantly more residents reported intention to use action plans with patients following participation. Themes from qualitative feedback included: valuing the overall experience, increasing opportunities to practice teaching, enhancing their ability to communicate with adolescents, contributing to the health of the community, recognizing the potential of action plans, and increasing intent to use action plans. CONCLUSIONS: This pilot demonstrated that a brief service-learning program can enhance standard residency curriculum by encouraging acquisition of ACGME competencies and promoting utilization of self-management support in clinical practice.

Teachers' perceptions of full- and part-time nurses at school.

Teachers and school nurses partner together to help ensure students stay healthy and engaged in school. The purpose of this study is to generate a deeper understanding of teachers' perceptions on the benefits and challenges of working with full- or part-time school nurses. We conducted a qualitative analysis of open-ended survey responses from 129 teachers in nine low-income, ethnically diverse urban schools. These schools were part of a multiyear project that placed full-time nurses in four schools, while five schools with part-time nurses were used as a comparison group. Findings indicate that teachers had strong appreciation for the wide range of responsibilities undertaken by the school nurse. Teachers' level of satisfaction was linked to the number of hours the nurse is on-site, where teachers reported greater satisfaction with nurses who worked on campus full time. Results point to factors that may improve working relations between teachers and nurses.

Training at-risk youth to become diabetes self-management coaches for family members: partnering family medicine residents with underserved schools.

PURPOSE: The purpose of this study is to evaluate the impact of a school-based health program in which family medicine residents trained healthy at-risk adolescents to become diabetes self-management coaches for family members with diabetes. METHODS: A mixed methods study included 97 adolescents from 3 San Francisco Bay Area high schools serving primarily ethnic minority youth of low socioeconomic status. Physicians came to schools once a week for 8 weeks and trained 49 adolescents to become coaches. Student coaches and 48 nonparticipant students completed pre- and posttest intervention questionnaires, and 15 student coaches and 9 family members with diabetes gave in-depth interviews after participation. Linear regression was used to determine differences in knowledge and psychosocial assets on pre- and posttests between student coaches and nonparticipant students, and NVIVO was used to analyze interview transcripts. RESULTS: After controlling for initial score, sex, grade, and ethnicity, student coaches improved from pre- to posttest significantly compared to nonparticipants on knowledge, belonging, and worth scales. Student coaches reported high satisfaction with the program. Articulated program benefits included improvement in diet, increased physical activity, and improved relationship between student coach and family member. CONCLUSIONS: Overall, this program can increase diabetes knowledge and psychosocial assets of at-risk youth, and it holds promise to promote positive health behaviors among at-risk youth and their families.

School nurses' role in asthma management, school absenteeism, and cost savings: a demonstration project.

BACKGROUND: With increasing budget cuts to education and social services, rigorous evaluation needs to document school nurses' impact on student health, academic outcomes, and district funding. METHODS: Utilizing a quasi-experimental design, we evaluated outcomes in 4 schools with added full-time nurses and 5 matched schools with part-time nurses in the San Jose Unified School District. Student data and logistic regression models were used to examine predictors of illness-related absenteeism for 2006-2007 and 2008-2009. We calculated average daily attendance (ADA) funding and parent wages associated with an improvement in illness-related absenteeism. Utilizing parent surveys, we also estimated the cost of services for asthma-related visits to the emergency room (ER; N = 2489). RESULTS: Children with asthma were more likely to be absent due to illness; however, mean absenteeism due to illness decreased when full-time nurses were added to demonstration schools but increased in comparison schools during 2008-2009, resulting in a potential savings of $48,518.62 in ADA funding (N = 6081). Parents in demonstration schools reported fewer ER visits, and the estimated savings in ER services and parent wages were significant. CONCLUSION: Full-time school nurses play an important role in improving asthma management among students in underserved schools, which can impact school absenteeism and attendance-related economic costs.

Chronic health conditions and school performance among children and youth.

PURPOSE: Chronic health conditions are common and increasing among U.S. children and youth. We examined whether chronic health conditions are associated with low school performance. METHODS: This retrospective cohort study of 22,730 children and youth (grades 2-11) in San Jose, California, was conducted from 2007 through 2010. Health conditions were defined as chronic if reported in each of the first 2 years, and school performance was measured using standardized English language arts (ELA) and math assessments. RESULTS: Chronic health conditions were independently associated with low ELA and math performance, irrespective of ethnicity, socioeconomic status, or grade level. Adjusted odds ratios for the association between any chronic health condition and low ("basic or below") performance were 1.25 (95% confidence interval [CI], 1.16-1.36; P < .001) for ELA and 1.28 (95% CI, 1.18-1.38; P < .001) for math, relative to students without reported health conditions. Further adjustment for absenteeism had little effect on these results. The strongest associations were found for ADHD, autism, and seizure disorders, whereas a weak association was found for asthma before but not after adjusting for absenteeism, and no associations were found for cardiovascular disorders or diabetes. CONCLUSIONS: Chronic neurodevelopmental and seizure disorders, but not cardiovascular disorders or diabetes, were independently associated with low school performance among children and youth.

Maternal unemployment and childhood overweight: is there a relationship?

BACKGROUND: Previous studies have shown a positive association between maternal work hours and childhood overweight. However, it is unclear what role job instability plays in this relationship; therefore, this study examined whether children whose mothers experienced unemployment were more likely to have greater increases in body mass index (BMI) as compared with children whose mothers were stably employed. The effects of unemployment benefits, welfare and number of hours worked were also explored. METHODS: A multiple regression analysis was used to analyse changes in BMI over a 4-year period using the National Longitudinal Survey of Youth. In all, 4890 US children, aged 2-16 at baseline, were included in the analysis. RESULTS: As compared with children of mothers who were employed full-time and did not receive welfare, children of mothers who experienced unemployment and received unemployment benefits were not more likely to have significantly different changes in BMI. Yet children of mothers who experienced unemployment and did not receive unemployment benefits were significantly more likely to have greater increases in BMI. These results were also shown in models which controlled for height. This supports the conclusion that adiposity changes, and not simply growth-rate differences, account for the different BMI changes between groups. CONCLUSION: Aspects of maternal employment other than number of work hours are associated with child BMI, including unemployment events and what type of support a mother receives during the time of unemployment. This has implications for policies that relate to benefits for mothers who lose their jobs.

The impact of education on care practices: an exploratory study of the influence of "action plans" on the behavior of health professionals.

BACKGROUND: There has been limited focus on evaluation of continuing education (CEU) and continuing medical education (CME) in the fields of gerontology and geriatrics. The increasing elderly population combined with the limited clinical workforce highlights the need for more effective methods of continuing education. Traditionally, outcomes of CEU and CME programs relied on self-report measures of satisfaction with the scope and quality of the training, but more recent efforts in this area have focused on outcomes indicating level of improved skills and attitudinal changes of medical and allied health professionals towards working with elderly patients in need of assistance. METHODS: This study focused on the use of "Action Plans" as a tool to stimulate changes in clinical programs following training, along with attempting to determine typical barriers to change and how to deal with them. More than 600 action plans were obtained from participants attending various continuing education classes providing training on care of patients with dementia (PWD) and their families. Both qualitative and quantitative methods, including logistic regression models were used to analyze the data. RESULTS: Three months following training 366 participants reported whether they were successful in implementing their action plans and identified factors that either facilitated or hindered their goal to make changes outlined in their action plans. Despite the low response rate of program participants, the "action plan" (with follow up to determine degree of completion) appeared to stimulate effective behavioral changes in clinicians working with dementia patients and their family members. Seventy three percent of the respondents reported at least some level of success in implementing specific changes. Specific details about barriers to change and how to overcome them are discussed. CONCLUSIONS: Our results support that developing and writing action plans can be a useful tool to self- monitor behavioral change among trainees over time.

Smoking, drinking and body weight after re-employment: does unemployment experience and compensation make a difference?

BACKGROUND: The impact of unemployment on behaviours such as smoking, drinking and body weight has been extensively researched. However, little is known about the possible protective effects of social assistance programs on these behavioural changes. This study examines the impact of unemployment periods on smoking, drinking and body weight changes among re-employed individuals and investigates whether the receipt of unemployment benefits influences these behaviours. METHODS: This study used panel data provided by the Panel Study of Income Dynamics. Logistic regression models were used to analyze whether a period of unemployment in 2000 resulted in an increase in smoking and drinking or fluctuations in body weight among 2001 re-employed individuals in comparison with 1999 baseline levels. A total of 3,451 respondents who had been initially healthy and who had been continuously employed between 1998 and 1999 were included in the analysis. RESULTS: Compared to stably employed respondents, those who had experienced periods of unemployment in 2000 and did not receive unemployment benefits were more likely than continuously employed individuals to report an increase in alcohol consumption (OR 1.8, 95% CI 1.0-3.1) and a decrease in body weight (OR 1.7, 95% CI 1.1-2.8) when they were already re-employed in 2001. CONCLUSION: Our findings suggest that the receipt of unemployment benefits confers a protective effect on health behavioural changes following periods of unemployment. These findings underscore the need to monitor the impact of unemployment assistance programs on health, particularly in light of the rapidly changing structure of employment and unemployment benefits.

Alcohol, employment status, and social benefits: one more piece of the puzzle.

OBJECTIVES: To examine the role of employment status and the receipt of social benefits in the prediction of alcohol use. METHODS: Logistic regression models were used to analyze panel data from the National Survey of Families and Households (NSFH) 1987-88 and 1991-92. A total of 7,599 respondents who were older than 16 years of age in 1987 and did not have a physical or mental condition were included in the analysis. The alcohol measures were (a) total number of drinks in the past 30 days; and (b) having 5 or more drinks in a day, 4 or more days in the past 30 days. RESULTS: Employed welfare recipient women have a greater likelihood of heavy drinking than other full-time employed. We do not find evidence of an association between not being employed (with or without benefits) and greater likelihood of engaging in heavy drinking behaviors. Alcohol drinking among other employment groups is not significantly different, with the exception of retired men who drink less. CONCLUSION: It is important to focus attention on women working while receiving welfare, and who may need help maintaining their jobs.

Types of provincial structure and population health.

This paper explores the potential of using large administrative units for studies of population health within a country. The objective is to illustrate a new way of defining structural dimensions and to use them in examining variation in life expectancy rates. We use data from the 50 provinces of Spain as a case study. A factor analysis of organizational items such as schools, hotels and medical personnel is employed to define and generate "collective" measures for well-known provincial types, in this case: urban, commercial, industrial and tourist provinces. The scores derived from the factor analysis are then used in a regression model to predict life expectancy. The City-centered and Commercial provinces showed positive correlations with life expectancy while those for the Tourist provinces were negative. The industrial type was nonsignificant. Explanations of these correlations are proposed and the advantages and disadvantages of this exploratory technique are reviewed. The use of this technique for generating an overview of social organization and population health is discussed.

Marginal employment and health in Britain and Germany: does unstable employment predict health?

This study examines the possible health impact of marginal employment, including both temporary and part-time employment schemes. It addresses three research questions: (1) Are employed people with a fixed-term contract or no contract more likely to report poor health than those who hold jobs with permanent contracts? (2) Are part-time employed respondents (even when they hold jobs with permanent contracts) more likely to report poor health than full-time workers? (3) Does change in employment stability (i.e., from employment with permanent contract to fixed-term or no contract employment and vice-versa) have an impact on health status? Logistic regression models were used to analyze panel data from Britain and Germany (1991-1993), available in the Household Panel Comparability Project data base. We included 10,104 respondents from Germany and 7988 from Britain. A single measure of perceived health status was used as the dependent variable. Controlling for background characteristics, the health status of part-time workers with permanent contracts is not significantly different from those who are employed full-time. In contrast, fulltime employed people with fixed-term contracts in Germany are about 42 per cent more likely to report poor health than those who have permanent work contracts. In Britain, only part-time work with no contract is associated with poor health, but the difference is not statistically significant. We conclude that monitoring the possible health effects of the increasing number of marginal employment arrangements should be given priority on the social welfare research agenda.