A Multicomponent Health Education Campaign Led by Community Health Workers to Increase Influenza Vaccination among Migrants and Refugees.

OBJECTIVES: To evaluate the impact of a Community Health Worker (CHW)-led influenza campaign on knowledge and attitudes about vaccination in Latinx migrant and refugee populations. METHODS: Twelve online workshops were conducted with 183 participants and 24 CHWs between January 12 and May 12, 2021. Participants were Latinx families living in underserved communities throughout Washington state. The initiative also included radio, animated videos, advertisements, social media, and educational materials. RESULTS: Analysis of pre and post workshop surveys from 155 participants showed statistically significant improvements in all questions about the definition of influenza, symptoms, and risks: and in 7 of 9 questions about treatments and vaccines. Analysis of 2 open-ended questions showed increases in words key to understanding influenza, such as "virus," "illness," "death," and "contagious." There were significant increases in rates of participants identifying vaccination and antibiotics as cures for influenza. CONCLUSIONS: CHW-led workshops can be an effective way to increase knowledge about influenza and influenza vaccine. Future curriculum should emphasize the difference between viruses and bacteria, and the use of vaccination for prevention as opposed to treatment for illness.

Correlation of Oral Health Education by Community Health Workers with Changes in Oral Health Practices in Migrant Populations in Washington State.

INTRODUCTION: An important question for oral health education is whether knowledge gained during lay-led workshops is retained and applied in daily practice. This study assessed the knowledge retention and changes in oral health practices several months after oral health education workshops were held for migrant farmworkers by Community Health Workers (CHWs). METHODS AND RESULTS: Follow-up surveys were conducted with 32 participants 1 to 43 months post participation (60% between 6 and 21 months). The results showed a high degree of retention, in such areas as general oral health knowledge, and brushing/flossing frequency and technique among this sample. There was no relationship between length of time since the educational workshop and knowledge retained or behaviors changed. CONCLUSIONS AND RECOMMENDATIONS: An interactive, lay-led oral health education program run by CHWs can be an effective way to deliver sustained improvements in oral health knowledge and changes in oral health practice in migrant populations.

Promoting changes in obesogenic behaviors: does coworker social support play a role?

PURPOSE: To examine the association between worksite social support and changes in diet, physical activity, and body mass index (BMI). DESIGN: Cohort analysis of an underlying randomized, controlled weight gain prevention worksite trial: Promoting Activity and Changes in Eating. SETTING: The trial occurred in the greater Seattle area. SUBJECTS: Baseline and follow-up data were obtained on a nested cohort of employees (n = 958-1078) from 33 small- to medium-sized worksites. MEASURES: Worksite social support, diet, physical activity, and BMI measures were assessed using a self-reported questionnaire. ANALYSIS: To adjust for multilevel data and multiple time points, we used generalized estimating equations and logistic mixed models. RESULTS: Higher baseline worksite social support was associated with greater changes in fruit and vegetable intake (p = .001; summary food-frequency questions). CONCLUSION: This study does not support a conclusive relationship between worksite social support and health behavior change.

Exploring the role of co-worker social support on health care utilization and sickness absence.

OBJECTIVES: To explore the association of baseline co-worker social support with follow-up measures of health care use and sickness absence. METHODS: Data were obtained on 1240 employees from 33 worksites, through Promoting Activity and Changes in Eating, a group randomized weight maintenance trial. Co-worker social support, health care utilization, and absenteeism were assessed via a self-reported questionnaire. Generalized Estimating Equations were employed using STATA version 10. RESULTS: Higher baseline co-worker social support was significantly associated with a greater number of doctors' visits (P = 0.015). Co-worker social support was unrelated to number of hospitalizations, emergency department visits, or absenteeism. CONCLUSIONS: The relationship between co-worker social support and health care utilization and absenteeism is complex and uncertain. Future studies should measure more specific outcomes, incorporate important mediating variables, and distill how social networks influence these outcomes.

The association between worksite social support, diet, physical activity and body mass index.

OBJECTIVE: Social support may be associated with improved diet and physical activity-determinants of overweight and obesity. Wellness programs increasingly target worksites. The aim was to evaluate the relationship between worksite social support and dietary behaviors, physical activity, and body mass index (BMI). METHOD: Baseline data were obtained on 2878 employees from 2005 to 2007 from 34 worksites through Promoting Activity and Changes in Eating, a group-randomized weight reduction intervention in Greater Seattle. Worksite social support, diet, physical activity, and BMI were assessed via self-reported questionnaire. Principal component analysis was applied to workgroup questions. To adjust for design effects, random effects models were employed. RESULTS: No associations were found with worksite social support and BMI, or with many obesogenic behaviors. However, individuals with higher worksite social support had 14.3% higher (95% CI: 5.6%-23.7%) mean physical activity score and 4% higher (95% CI: 1%-7%) mean fruit and vegetable intake compared to individuals with one-unit lower support. CONCLUSION: Our findings do not support a conclusive relationship between higher worksite social support and obesogenic behaviors, with the exception of physical activity and fruit and vegetable intake. Future studies are needed to confirm these relationships and evaluate how worksite social support impacts trial outcomes.

Health care utilization and its costs for depressed veterans with and without comorbid PTSD symptoms.

OBJECTIVE: This study examined health care utilization and costs of care among Veterans Affairs (VA) patients with depression and with or without symptoms of comorbid posttraumatic stress disorder (PTSD). METHODS: Cross-sectional comparisons of health care utilization and costs were conducted with VA administrative data for a sample of veterans from a randomized trial of collaborative care depression treatment in ten VA primary care clinics across five states. Patients with depression or dysthymia were included in the study, and those who were acutely suicidal or had probable bipolar disorder were excluded. The sample of 606 patients was mainly male, white, and aged 55 or older. Health care utilization, costs, and medication data from VA administrative databases were analyzed over 12 months. RESULTS: Patients with depression and PTSD (screen score > or =3) were more emotionally distressed, had more frequent mental health specialty visits (6.91 versus 1.68, p<.001), more total outpatient visits (26.16 versus 19.94, p<.001), and correspondingly higher outpatient mental health care costs over the previous 12 months compared with depressed patients without PTSD. Antidepressants were prescribed to a higher proportion of depressed patients with PTSD (61% versus 40%). CONCLUSIONS: Patients with PTSD and depression had greater utilization of specialty mental health treatments and antidepressant medications and higher mental health care costs in the previous 12 months than depressed patients without PTSD. As military personnel return from Iraq, both VA and non-VA health care providers need to plan for an increase in outpatient mental health services and costs, particularly among depressed veterans who also have PTSD.

Expanding the role of nurse practitioners: effects on rural access to care for injured workers.

CONTEXT: A 3-year pilot program to expand the role of nurse practitioners (NPs) in the Washington State workers' compensation system was implemented in 2004 (SHB 1691), amid concern about disparities in access to health care for injured workers in rural areas. SHB 1691 authorized NPs to independently perform most functions of an attending physician. PURPOSE: The aims of this study were to (1) describe the contribution by NPs to Washington's workers' compensation provider workforce, (2) evaluate change in provider availability attributable to SHB 1691, and (3) evaluate the effect of SHB 1691 on timely accident report filing. METHODS: Administrative data were used to evaluate this natural experiment, using a pre-post design with primary care physicians (PCPs) as a nonequivalent comparison group. FINDINGS: NPs served injured workers with characteristics similar to those served by PCPs, but 22.0% of NPs were rural, compared with 17.3% of PCPs. Of claimants with NPs as their attending provider, 53.3% were injured in a rural county, compared with 24.7% for those with PCP attending providers. The number of NPs participating in the workers' compensation system rose after SHB 1691 implementation, more so in rural areas. SHB 1691 implementation was associated with a 16 percentage point improvement in timely accident report filing by NPs in both rural and urban areas. CONCLUSIONS: Authorizing NPs to function as attending providers for injured workers may improve provider availability (especially in rural areas) and timely accident report filing, which in turn may improve worker outcomes and system costs.

A lifestyle-based weight management program delivered to employees: examination of health and economic outcomes.

OBJECTIVE: To examine the health and economic outcomes associated with a comprehensive weight management program delivered to employees. METHODS: Data collected on 516 individuals participating in a lifestyle-based weight management program delivered to employees from three corporations were analyzed at baseline and intervention-end (26 or 52 weeks). One-year post-intervention data for two subgroups were examined for pharmaceutical use (n = 61) and health outcomes (n = 46). RESULTS: Average body weight decreased 5.4% (P < 0.001) and average waist circumference decreased 7.2% (P < 0.001). Average blood pressure, Beck Depression Inventory scores, and Rosenberg Self-Esteem Scale scores improved (P < 0.001). At 1-year post-intervention, weight loss was maintained in a subgroup of 46 individuals. The average number of prescription drugs taken per participant decreased 44% in a subgroup of 61 individuals. CONCLUSIONS: An employer-sponsored, comprehensive weight management program may decrease weight, improve obesity-related outcomes, improve depressive symptoms, and decrease costs.

Nurse practitioners as attending providers for injured workers: evaluating the effect of role expansion on disability and costs.

BACKGROUND: A 3-year pilot program to expand the role of nurse practitioners (NPs) in the Washington State workers' compensation system was implemented on July 1, 2004. This legislation authorized NPs to independently perform most functions of an attending physician. OBJECTIVE: The purpose of this study was to assess the impact of this legislation by examining medical costs and disability outcomes for injured workers in the care of NPs benchmarked against those in the care of primary care physicians (PCPs). RESEARCH DESIGN: This observational study compared NPs and PCPs in the role of attending provider based on the medical costs and disability outcomes of injured workers in their care. Comparisons controlled for sociodemographics, geographic location, injury, employment, and provider characteristics. DATA SOURCE: The Washington State Department of Labor and Industries provided claim and medical billing data for 29,949 injured workers who had an accident report filed by an NP or PCP between July 1, 2004 and June 30, 2005. Data were collected through June 30, 2006. RESULTS: NPs were more likely than PCPs to be located in rural areas and counties with high unemployment. The distributions of injury type and severity/complexity indicators were similar across provider types. The likelihood of any time loss was lower for NP claims, but duration of lost work time and medical costs did not significantly differ by provider type. CONCLUSIONS: Attending provider type is not a significant predictor of disability or medical costs for injured workers in Washington State.

Nurse practitioners as attending providers for workers with uncomplicated back injuries: using administrative data to evaluate quality and process of care.

OBJECTIVE: The objectives of this study were 1) to identify quality and process of care indicators available in administrative workers' compensation data and to document their association with work disability outcomes, and 2) to use these indicators to assess whether nurse practitioners (NPs), recently authorized to serve as attending providers for injured workers in Washington State, performed differently than did primary care physicians (PCPs). METHODS: Quality and process of care indicators for NP and PCP back injury claims from Washington State were compared using direct standardization and logistic regression. RESULTS: This study found little evidence of differences between NP and PCP claims in case mix or quality of care. CONCLUSIONS: The process of care indicators that we identified were highly associated with the duration of work disability and have potential for further development to assess and promote quality improvement.

Attributes of environments supporting walking.

PURPOSE: This study established a framework to audit environments supporting walking in neighborhoods. DESIGN: Cross-sectional analysis using a telephone survey and 200 objective environmental variables. SETTING. Urbanized King County, WA. SUBJECTS. 608 randomly sampled adults. Measures. Walking measures constructed from survey questions; objective environmental measures taken from parcel-level databases in Geographic Information Systems. ANALYSIS: Multinomial models estimated the odds of people engaging in moderate walking (<149 min/wk) and in walking sufficiently to meet recommendations for health (150+ min/ wk), relative to not walking" and in walking sufficiently, relative to walking moderately. A base model consisted of survey variables, and final models incorporated both survey and environmental variables. RESULTS. Survey variables strongly associated with walking sufficiently to enhance health included household income, not having difficulty walking, using transit, perceiving social support for walking walking outside of the neighborhood, and having a dog (p < .01). The models isolated 14 environmental variables associated with walking sufficiently (pseudo R2 up to 0. 46). Measures of distance to neighborhood destinations dominated the results: shorter distances to grocery stores/markets, restaurants, and retail stores, but longer distances to offices or mixed-use buildings (p < .01 or .05). The density of the respondent's parcel was also strongly associated with walking sufficiently (p < .01). Conclusions. The study offered valid environmental measures of neighborhood walkability.

Operational Definitions of Walkable Neighborhood: Theoretical and Empirical Insights.

BACKGROUND: The concept of walkable neighborhoods is increasingly important in physical activity research and intervention. However, limited theoretical understanding and measurable definitions remain a challenge. METHODS: This paper reviews theories defining neighborhoods and offers an empirical approach to identify measurable attributes and thresholds of walkable neighborhoods. Bivariate and multivariate analyses are used for self-reported socio-demographic background, neighborhood walking behavior and perception, and objective measures of environments. RESULTS: Environmental attributes positively associated with walking sufficiently to meet health recommendations included higher residential density and smaller street-blocks around home, and shorter distances to food and daily retail facilities from home. Threshold distances for eating/drinking establishments and grocery stores were 860 and 1445 feet. CONCLUSIONS: Results questioned theoretical constructs of neighborhoods centered on recreation and educational uses. They pointed to finer mixes of uses than those characterizing suburban neighborhoods, and small spatial units of analysis and intervention to capture and promote neighborhood walkability.

Increasing minority representation in the health professions.

Research indicates that health disparities may be reduced by increasing the number of ethnic minorities working in health occupations. Establishing health career pathway programs for immigrant and ethnic minority students is one way to address this problem. One such program, Cross-Cultural Education in Public Health (CCEPH), was developed, implemented, and evaluated to determine whether participants expressed greater interest in pursuing health care careers after program completion. A sample of 72 immigrant students in two high schools participated in the program, which was based on Bandura's theory of self-efficacy. Data were gathered using pre- and postprogram surveys that measured academic self-efficacy and career consideration. Results for academic efficacy were not statistically significant, but interest level in health care careers rose substantially. Although further research needs to be conducted to determine whether such programs increase self-efficacy, programs such as CCEPH can increase the consideration of health careers among immigrant and ethnic minority students.

Self-management support in a web-based medical record: a pilot randomized controlled trial.

Physicians were much less likely than other primary care team members to use a Web-based application to counsel patients with diabetes about behavior change.

A multifaceted intervention in support of diabetes treatment guidelines: a cont trial.

OBJECTIVE: in an academic family practice clinic, we performed a controlled trial of a multifaceted intervention versus usual care for managing diabetes. Providers received didactic training and computerized compliance feedback to support staged diabetes management, an evidenced-based approach to diabetes care. RESEARCH DESIGN AND METHODS: one firm of the clinic practice received the intervention, the other served as the control group during a 14-month baseline period and a 14-month study period. HbA1(c) was the principal outcome measure. RESULTS: there was a significant 0.71% difference in change in HbA1(c) values between the intervention and control firms (P=0.02). The subgroup with the greatest improvement in HbA1(c) was those subjects who started the intervention with a HbA1(c) above 8%. The overall improvement in glycemic control could not be explained by differences in visit frequency or the aggressiveness of drug therapy. There were no changes in healthcare utilization or costs between the two firms. CONCLUSION: in an academic family practice clinic, a multifaceted intervention in support of diabetes treatment guidelines modestly improved glycemic control without incurring additional costs. The improvement was mostly due to mitigation of the natural deterioration in control usually seen. Further efforts are required to involve all patients in co-managing their diabetes.

Evidence-based management: using serial firm trials to improve diabetes care quality.

BACKGROUND: The design of delivery systems that can truly conduct continuous quality improvement (CQI) as a routine part of clinical care provision remains a vexing problem. The effectiveness of the "computerized firm system" approach to chronic disease CQI was examined, with diabetes as the focus of a 5-year case study. METHODS: A large family medical center had been divided into two parallel group practices for reasons of efficiency. These frontline structures (also known as primary care "firms") were supported to serially adapt and evaluate selected CQI interventions by first introducing process changes on one firm but not the other and comparing the groups. Because all the required longitudinal data were contained in a computerized repository, it was possible to conduct these controlled "firm trials" in a matter of months at low cost. RESULTS: During a 3-year period, implementation of point-of-service reminders and a pharmacist out-reach program increased recommended glycohemoglobin (HbA1c) testing by 50% (p = 0.02) and reduced the number of diabetic patients inadequately controlled by 43% (p < 0.01). Following this outcome improvement, patients exhibited a 16% reduction in ambulatory visit rates (p = 0.04). The observed outcome improvement, however, was reversed during the subsequent 2 years, when staffing austerities forced by unrelated declines in clinic revenue caused the withdrawal of trial interventions. CONCLUSIONS: The processes and outcomes of diabetes care were improved, demonstrating that CQI and controlled trials are not mutually exclusive in moving toward the practice of evidence-based management. Health care systems can, by conducting serial firm trials, become learning organizations. CQI programs of all kinds will likely never flourish, however, until quality improvement and reimbursement mechanisms have become better aligned.