Community Health Centers Uptake of Telemedicine During the COVID-19 Pandemic: Trends, Barriers, and Successful Strategies.

OBJECTIVE: To describe telemedicine use patterns and understand clinic's approaches to shifting care delivery during the COVID-19 pandemic. METHODS: We used electronic health record data from 203 community health centers across 13 states between 01/01/2019 and 6/31/2021 to describe trends in telemedicine visit rates over time. Qualitative data were collected from 13 of those community health centers to understand factors influencing adoption and implementation of telemedicine. RESULTS: Most clinics in our sample were in urban areas (n = 176) and served a majority of uninsured and publicly insured patients (12.8% and 44.4%, respectively) across racial and ethnic minority groups (16.6% Black and 29.3% Hispanic). During our analysis period there was a 791% increase in telemedicine visits from before the pandemic (.06% pre- vs 47.5% during). A latent class growth analysis was used to examine differences in patterns of adoption of telemedicine across the 203 CHCs. The model resulted in 6 clusters representing various levels of telemedicine adoption. A mixed methods approach streamlined these clusters into 4 final groups. Clinics that reported rapid adoption of telemedicine attributed this change to leadership prioritization of telemedicine, robust quality improvement processes (eg, using PDSA processes), and emphasis on training and technology support. CONCLUSIONS: In response to the COVID-19 pandemic, telemedicine adoption rates varied across clinics. Our study highlight that organizational factors contributed to the clinic's ability to rapidly uptake and use telemedicine services throughout the pandemic. These approaches could inform future non-pandemic practice change and care delivery.

Park Space, Movement and Equity: Support of Physical Activity per Square Foot by Park Features.

Given the finite space available for parks in most urban areas, understanding the impact of design and park amenities on park visitation and physical activity should be considered when remodeling or creating new parks. This study analyzed park use and engagement in moderate-to-vigorous physical activity (MVPA) in specific park amenities across 198 parks in 27 US cities from the 2016 National Study of Neighborhood Parks based on each feature's square footage. The study also specifically measured use of park space by age group and gender. After mapping the parks, measuring the square feet of the most common amenities and controlling for factors like population density, neighborhood poverty levels, and park size, we found varied and inequitable use of amenities by age and gender, with men and boys having considerably greater use than women and girls. The findings suggest that park management and design should support more efficient, equitable, and beneficial use of public spaces.

City-Level Sugar-Sweetened Beverage Taxes and Youth Body Mass Index Percentile.

Importance: Levying excise taxes on sugar-sweetened beverage (SSB) distributors, which are subsequently passed on to consumers, is a policy implemented to reduce the high prevalence of cardiometabolic disease and generate public health funding. Taxes are associated with lower SSB purchases and consumption, but it is unknown whether they are associated with weight-related outcomes in youth. Objective: To determine the association of SSB excise taxes with youth body mass index (BMI) trajectories. Design, Setting, and Participants: This cohort study was conducted from 2009 to 2020, including 6 years before tax implementation and 4 to 6 years after tax implementation. The California cities of Albany, Berkeley, Oakland, and San Francisco, which implemented SSB excise taxes, were compared against 40 demographically matched control cities in California. Participants included Kaiser Permanente members aged 2 to 19 years at cohort entry (baseline) with continuous residence in selected cities with at least 1 pretax and 1 posttax BMI recorded in their electronic health record. Data analysis was performed from January 2021 to May 2023. Exposure: Implementation of SSB excise taxes. Main Outcomes and Measures: Centers for Disease Control and Prevention age-specific and sex-specific BMI percentiles and percentage of youth with overweight or obesity before tax implementation through 4 to 6 years after implementation were compared with control cities. Statistical analysis was conducted using the difference-in-differences (DID) method. A sensitivity analysis used the synthetic control method. Results: A total of 44 771 youth (mean [SD] age at baseline, 6.4 [4.2] years; 22 337 female [49.9%]) resided in the cities with SSB taxes; 345 428 youth (mean [SD] age, 6.9 [4.2] years; 171 0168 female [49.5%]) resided in control cities. There was a -1.64-percentage point (95% CI, -3.10 to -0.17 percentage points) overall difference in the mean change of BMI percentile between exposure and control cities after SSB tax implementation. There was no significant overall difference in the percentage of youth with overweight or obesity or youth with obesity compared with control cities. All DID estimates were significant for youth residing in exposure cities in terms of BMI percentile (age 2-5 years in 2017, -2.06 percentage points [95% CI, -4.04 to -0.09 percentage points]; age 6-11 years in 2017, -2.79 percentage points [95% CI, -4.29 to -1.30 percentage points]), percentages of youth with overweight or obesity (age 2-5 years, -5.46 percentage points [95% CI, -8.47 to -2.44 percentage points]; age 6-11 years, -4.23 percentage points [95% CI, -6.90 to -1.57 percentage points]), and percentages of youth with obesity (age 2-5 years; -1.87 percentage points [95% CI, -3.36 to -0.38 percentage points]; age 6-11 years, -1.85 percentage points [95% CI, -3.46 to -0.24 percentage points]). Compared with control cities, changes in mean BMI percentiles were significant for male (-1.98 percentage points; 95% CI, -3.48 to -0.48 percentage points), Asian (-1.63 percentage points; 95% CI, -3.10 to -0.16 percentage points), and White (-2.58 percentage points; 95% CI, -4.11 to -1.10 percentage points) youth. Compared with control cities, White youth in exposure cities had improvements in the percentage with overweight or obesity (-3.73 percentage points; 95% CI, -6.11 to -1.35 percentage points) and the percentage with obesity (-2.78 percentage points; 95% CI, -4.18 to -1.37 percentage points). Conclusions and Relevance: In this cohort study, SSB excise taxes were associated with lower BMI percentile among youth. Policymakers should consider implementing SSB excise taxes to prevent or reduce youth overweight and obesity and, ultimately, chronic disease, particularly among children younger than 12 years.

Substance use approaches among peer support specialists in community mental health early psychosis programs.

OBJECTIVE: Substance use (SU) is common among adolescents and young adults, including those experiencing early psychosis. Coordinated Specialty Care (CSC), a community-based multidisciplinary team-based service model, is increasingly used to support people experiencing first-episode psychosis. In addition to prescribers, clinicians, and vocational specialists, CSC includes peer support specialists who use their own living/lived experience with mental health and treatment to engage and support young people with their recovery goals. Peer support is also foundational in SU recovery. However, little is known about how peer support specialists navigate client SU in CSC. The purpose of this article is to detail CSC peer support SU practice. METHOD: Informed by community-based participatory research methods, a PhD-level qualitative researcher and a former peer support specialist conducted virtual interviews with 20 CSC peer support specialists. A multidisciplinary team including researchers with lived mental health experiences thematically coded interview transcripts. RESULTS: A spectrum of CSC peer support specialist SU responses emerged: (a) leverages lived SU experiences; (b) does not explore SU with clients; (c) shares client SU information with the CSC team; (d) educates, mentors, and advocates; (e) shares SU consequences and/or challenges substance use; (f) nonjudgmental, nondirective SU exploration; and (g) promotes harm reduction. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE: CSC peer specialist SU practice is influenced by several contextual tensions that must be better understood and addressed in future research to improve peer SU practice. Study findings speak to practice nuances that are helpful for CSC peer support training and supervision. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

The Effect of City-Level Sugar-Sweetened Beverage Taxes on Longitudinal HbA1c and Incident Diabetes in Adults With Prediabetes.

OBJECTIVE: Prediabetes, which is a condition characterized by higher-than-normal blood glucose levels that are under the threshold for diabetes, impacts over one-third of U.S. adults. Excise taxes on sugar-sweetened beverages (SSBs) are a proposed policy intervention to lower population consumption of SSBs and generate revenue to support health-related programs, thus potentially delaying or preventing the development of diabetes in individuals with prediabetes. We leveraged data from Kaiser Permanente in California to examine the impact of SSB taxes in California on individual-level mean HbA1c levels and rates of incident diabetes. RESEARCH DESIGN AND METHODS: We compared two outcomes, mean HbA1c levels and rates of incident diabetes, among a matched cohort of adults with prediabetes who lived and did not live in SSB excise tax cities, using outcomes collected in the 6 years prior and 4 years following SSB tax implementation. We used multivariable linear mixed effects models to analyze longitudinal mean HbA1c and discrete-time survival models for incident diabetes. RESULTS: We included 68,658 adults in the analysis. In adjusted models, longitudinal mean HbA1c was 0.007% (95% CI 0.002, 0.011) higher in the tax cities compared with control individuals; while the estimated difference was statistically significant, it was not clinically significant (HbA1c <0.5%). There was no significant difference in the risk of incident diabetes between individuals living in tax and control cities. CONCLUSIONS: We found no clinically significant association between SSB taxes and either longitudinal mean HbA1c or incident diabetes among adults with prediabetes in the 4 years following SSB tax implementation.

Feasibility and Acceptability of Standardizing Portions in Restaurants.

Most restaurants serve customers excess calories which significantly contributes to the obesity epidemic. This pilot study tested the feasibility and acceptability of offering customers standardized portions to reduce caloric consumption when dining out in three restaurants. Portions were developed to limit quantity of food served, with lunches and dinners ≤ 700 cal and breakfast ≤ 500 cal. Participating restaurants developed an alternative "Balanced Portions Menu." Training and instructions were provided with respect to the volume and weight of food to be plated following the standardized guidelines and providing at least one cup of vegetables per lunch/dinner. We invited local residents to help us evaluate the new menu. We monitored restaurant adherence to guidelines, obtained feedback from customers, and incentivized customers to complete dietary recalls to determine how the new menus might have impacted their daily caloric consumption. Of the three participating restaurants, all had a positive experience after creating the new menus and received more foot traffic. One restaurant that did not want to change portion sizes simply plated the appropriate amount and packed up the rest to-go, marketing the meals as "Dinner today, lunch tomorrow." Two of the restaurants followed the guidelines precisely, while one sometimes plated more rice than the three-fourths cup that was recommended. A significant number of customers ordered from the Balanced Portions menus. Two of the three restaurants have decided to keep offering the Balanced Portions menus indefinitely. Following standardized portions guidelines is both feasible for restaurants and acceptable to customers.

Measuring Primary Care Spending in the US by State.

This case series identifies states' estimates of primary care spending and recommends steps policymakers can take toward standardizing these estimates.

Association Between Park Use and Moderate-to-Vigorous Activity During COVID-19 Years among a Cohort of Low-Income Youth.

Neighborhood parks are important venues to support moderate-to-vigorous (MVPA) activity. There has been a noticeable increase promoting physical activity among youth in neighborhood parks. This paper aims to assess the association between park use and MVPA among low-income youth in a large urban area. We recruited a cohort of 434 youth participants during the COVID pandemic years (2020-2022) from low-income households in Washington, D.C. We collected multiple data components: accelerometry, survey, and electronic health record data. We explored the bivariate relationship between the accelerometer-measured daily MVPA time outcome and survey-based park use measures. A mixed-effect model was fitted to adjust the effect estimate for participant-level and time-varying confounders. The overall average daily MVPA time is 16.0 min (SD = 12.7). The unadjusted bivariate relation between daily MVPA time and frequency of park visit is 1.3 min of daily MVPA time per one day with park visits (p < 0.0001). The model-adjusted estimate is 0.7 daily MVPA minutes for 1 day with park visit (p = 0.04). The duration of a typical park visit is not a significant predictor to daily MVPA time with or without adjustments. The initial COVID outbreak in 2020 resulted in a significant decline in daily MVPA time (- 4.7 min for 2020 versus 2022, p < 0.0001). Park visit frequency is a significant predictor to low-income youth's daily MVPA time with considerable absolute effect sizes compared with other barriers and facilitators. Promoting more frequent park use may be a useful means to improve low-income youth's MVPA outcome.

An Affordable and Sustainable Thrifty-Like Meal Plan, FoodRx, That Meets the Recommended Dietary Allowances.

There is considerable controversy as to whether a healthy diet is affordable given recent inflation. In order to determine whether a healthy, climate-friendly sustainable diet can be obtained within the allotments of the Supplemental Nutrition Assistance Program (SNAP), we created and purchased 26 weeks of meal plans designed to meet the EAT-Lancet sustainability guidelines and > 90% of the RDAs for 23 macro/micronutrients for households with at least 2 adults and 1-3 children. We compared the food quantities and cost of a healthy sustainable diet purchased in Los Angeles, 2023, to the Thrifty Food Plan, 2021. We compared the volume of food and cost of basic groceries to those recommended in the Thrifty Food Plan, 2021. The costs of the sustainable diet fell within the 2023 SNAP allotments as long as the average calories required per person did not exceed 2000. The volume of fruits, vegetables, legumes, nuts, and seeds were considerably higher for the sustainable diet compared to the Thrifty Food Plan. Given that calorie needs are the determinants of food quantity and costs, the USDA may consider offering supplemental coverage for individuals with higher calorie needs to make healthy eating affordable.

Global prediction of extreme floods in ungauged watersheds.

Floods are one of the most common natural disasters, with a disproportionate impact in developing countries that often lack dense streamflow gauge networks1. Accurate and timely warnings are critical for mitigating flood risks2, but hydrological simulation models typically must be calibrated to long data records in each watershed. Here we show that artificial intelligence-based forecasting achieves reliability in predicting extreme riverine events in ungauged watersheds at up to a five-day lead time that is similar to or better than the reliability of nowcasts (zero-day lead time) from a current state-of-the-art global modelling system (the Copernicus Emergency Management Service Global Flood Awareness System). In addition, we achieve accuracies over five-year return period events that are similar to or better than current accuracies over one-year return period events. This means that artificial intelligence can provide flood warnings earlier and over larger and more impactful events in ungauged basins. The model developed here was incorporated into an operational early warning system that produces publicly available (free and open) forecasts in real time in over 80 countries. This work highlights a need for increasing the availability of hydrological data to continue to improve global access to reliable flood warnings.

Evidence-based practice attitudes and nutrition support guideline knowledge between holders and nonholders of the Certified Nutrition Support Clinician credential.

BACKGROUND: Clinical practice frequently changes, and professionals should stay abreast of evidence-based practice (EBP) guidelines. Negative attitudes towards EBP are a barrier to guideline adoption. This study explored EBP attitudes and knowledge of a complex nutrition support clinical case scenario of individuals holding or not holding the Certified Nutrition Support Clinician (CNSC) credential. METHODS: This cross-sectional study used an online survey sent to American Society for Parenteral and Enteral Nutrition (ASPEN) members with and without the CNSC credential and all CNSC credential holders from the National Board of Nutrition Support Certification email list. The survey included the Evidence-Based Practice Attitude Scale Score (EBPAS-15) and eight knowledge questions using a nutrition support case scenario. An independent samples t test compared knowledge and EBPAS-15 total scores and subscores between CNSC holders and nonholders. Pearson correlation determined the correlation between knowledge and EBPAS-15 scores. RESULTS: The response rate was 7.8% (N = 706). CNSC holders (n = 536) had significantly higher mean knowledge scores (4.7 ± 1.6 out of 8) than nonholders (n = 159, 4.1 ± 1.7) (P < 0.001). Total EBPAS-15 scores were not significantly different between CNSC holders (n = 542, 2.9 ± 0.4 out of 4) and nonholders (n = 164, 2.8 ± 0.7) (P = 0.434), and knowledge scores and total EBPAS-15 scores (P = 0.639) or subscores were not significantly correlated. CONCLUSIONS: Regardless of holding the CNSC credential, EBPAS-15 scores indicated respondents had positive EBP attitudes. CNSC holders had significantly higher knowledge scores of recent nutrition support EBP guidelines compared with non-CNSC credential holders. Positive EBP attitudes are a precursor to clinical decision-making, but future research should determine the use of guidelines in clinical practice.

Patients' and Clinicians' Experiences with In-person, Video, and Phone Modalities for Opioid Use Disorder Treatment: A Qualitative Study.

BACKGROUND: Opioid use disorder (OUD) is a chronic condition that requires regular visits and care continuity. Telehealth implementation has created multiple visit modalities for OUD care. There is limited knowledge of patients' and clinicians' perceptions and experiences related to multi-modality care and when different modalities might be best employed. OBJECTIVE: To identify patients' and clinicians' experiences with multiple visit modalities for OUD treatment in primary care. DESIGN: Comparative case study, using video- and telephone-based semi-structured interviews. PARTICIPANTS: Patients being treated for OUD (n = 19) and clinicians who provided OUD care (n = 15) from two primary care clinics within the same healthcare system. APPROACH: Using an inductive approach, interviews were analyzed to identify patients' and clinicians' experiences with receiving/delivering OUD care via different visit modalities. Clinicians' and patients' experiences were compared using a group analytical process. KEY RESULTS: Patients and clinicians valued having multiple modalities available for care, with flexibility identified as a key benefit. Patients highlighted the decreased burden of travel and less social anxiety with telehealth visits. Similarly, clinicians reported that telehealth decreased medical intrusion into the lives of patients stable in recovery. Patients and clinicians saw the value of in-person visits when establishing care and for patients needing additional support. In-person visits allowed the ability to conduct urine drug testing, and to foster relationships and trust building, which were more difficult, but not impossible via a telehealth visit. Patients preferred telephone over video visits, as these were more private and more convenient. Clinicians identified benefits of video, including being able to both hear and see the patient, but often deferred to patient preference. CONCLUSIONS: Considerations for utilization of visit modalities for OUD care were identified based on patients' needs and preferences, which often changed over the course of treatment. Continued research is needed determine how visit modalities impact patient outcomes.

How Young Adults with Serious Mental Health Diagnoses Navigate Poverty Post-emancipation: The Complex Roles of Community Mental Health Services & Informal Social Support.

Serious mental health diagnoses are prevalent among youth who "age out" of foster care by reaching the maximum age for child welfare service eligibility. Post-emancipation, little is known about how youth engage in community mental health services, or leverage informal social networks, to navigate independence. Twenty emancipating youth completed three interviews over 16 months. All emancipated into poverty; most lived alone and initially connected to adult community mental health teams. Four service use and informal support profiles emerged from analysis: (1) Navigators (n = 2) actively used mental health services and provided limited informal support; Treaders (n = 9) passively used mental health services and heavily exchanged informal support; Survivors (n = 5) used mental health services when in crisis and heavily provided informal support; and Strugglers (n = 4) avoided mental health services and took resources from informal connections. Findings have implications for both child and adult mental health and social service providers.

Food recovery and produce distribution as a system strategy for increasing access to healthy food among populations experiencing food insecurity: lessons for post-pandemic planning.

Using data from an intercept survey of 428 adults who received free surplus produce at five distribution sites and qualitative data from 15 interviews with site personnel, we examined facilitators (e.g. community partnerships, coalition support) and challenges (e.g. limited refrigerated storage, lack of transportation infrastructure) to operating a food recovery and distribution program in Los Angeles County. Overall, this food system intervention appeared to fill an unmet need for recipients, nearly 80% of whom were food insecure and 60% visited a site several months/year or monthly. For many living in this county's underserved communities, this effort was instrumental in increasing access to healthy food before and during the COVID-19 pandemic. To sustain/expand this program's reach, local governments and food assistance programs should provide greater coordination and oversight, and invest more resources into this food recovery and distribution infrastructure.

Older People's Descriptions of Their Engagement in Fall Prevention.

Evidence-based strategies to decrease fall rates are well established. However, little is understood about how older people engage in fall prevention strategies. Motivational Interviewing (MI) sessions aimed to facilitate individuals' engagement in fall prevention can be analyzed to learn what it means for older people to engage in fall prevention. Thus, the purpose of this study was to explore how older people describe their engagement in fall prevention. Participants in our parent project, MI for Fall Prevention (MI-FP), who received MI sessions were purposively selected for maximum variation in age, sex, fall risks, and MI specialist assigned. The first (of 8) MI sessions from 16 participants were recorded, transcribed, and analyzed using qualitative content analysis. Three researchers first deductively analyzed fall prevention strategies that participants described using an evidence-based fall prevention guideline as a reference. Then, we inductively analyzed the characteristics of these strategies and how participants engaged in them. Finally, we used the Capability, Opportunity, Motivation, Behavior (COM-B) model to organize our results about factors influencing engagement. We found (1) older adults engage in unique combinations of fall prevention strategies and (2) decisions about engagement in fall prevention strategies were influenced by multiple factors that were personal (e.g., who I am, capability, motivation, and opportunities). This study highlighted how fall prevention can be a life-long lifestyle decision for older people. Understanding older people's perspectives about engaging in fall prevention is essential to develop interventions to promote evidence-based fall prevention strategies in real-world settings.