Reducing Firearm Access for Suicide Prevention: Implementation Evaluation of the Web-Based "Lock to Live" Decision Aid in Routine Health Care Encounters.

Background: "Lock to Live" (L2L) is a novel web-based decision aid for helping people at risk of suicide reduce access to firearms. Researchers have demonstrated that L2L is feasible to use and acceptable to patients, but little is known about how to implement L2L during web-based mental health care and in-person contact with clinicians. Objective: The goal of this project was to support the implementation and evaluation of L2L during routine primary care and mental health specialty web-based and in-person encounters. Methods: The L2L implementation and evaluation took place at Kaiser Permanente Washington (KPWA)-a large, regional, nonprofit health care system. Three dimensions from the RE-AIM (Reach, Effectiveness, Adoption, Implementation, Maintenance) model-Reach, Adoption, and Implementation-were selected to inform and evaluate the implementation of L2L at KPWA (January 1, 2020, to December 31, 2021). Electronic health record (EHR) data were used to purposefully recruit adult patients, including firearm owners and patients reporting suicidality, to participate in semistructured interviews. Interview themes were used to facilitate L2L implementation and inform subsequent semistructured interviews with clinicians responsible for suicide risk mitigation. Audio-recorded interviews were conducted via the web, transcribed, and coded, using a rapid qualitative inquiry approach. A descriptive analysis of EHR data was performed to summarize L2L reach and adoption among patients identified at high risk of suicide. Results: The initial implementation consisted of updates for clinicians to add a URL and QR code referencing L2L to the safety planning EHR templates. Recommendations about introducing L2L were subsequently derived from the thematic analysis of semistructured interviews with patients (n=36), which included (1) "have an open conversation," (2) "validate their situation," (3) "share what to expect," (4) "make it accessible and memorable," and (5) "walk through the tool." Clinicians' interviews (n=30) showed a strong preference to have L2L included by default in the EHR-based safety planning template (in contrast to adding it manually). During the 2-year observation period, 2739 patients reported prior-month suicide attempt planning or intent and had a documented safety plan during the study period, including 745 (27.2%) who also received L2L. Over four 6-month subperiods of the observation period, L2L adoption rates increased substantially from 2% to 29% among primary care clinicians and from <1% to 48% among mental health clinicians. Conclusions: Understanding the value of L2L from users' perspectives was essential for facilitating implementation and increasing patient reach and clinician adoption. Incorporating L2L into the existing system-level, EHR-based safety plan template reduced the effort to use L2L and was likely the most impactful implementation strategy. As rising suicide rates galvanize the urgency of prevention, the findings from this project, including L2L implementation tools and strategies, will support efforts to promote safety for suicide prevention in health care nationwide.

Building Public Health Competencies for Cross-Sector Leadership: Results From the National Leadership Academy for the Public's Health.

Context. The public health workforce is increasingly being asked to provide leadership in addressing complex community health needs. Effective leadership requires adaptiveness and cross-sector collaboration in developing solutions to address community needs. Program. An annual yearlong public health leadership development program, which engages cross-sector teams and uses an iterative design to build competencies for adaptive and collaborative leadership across sectors (e.g., public health, business, education, nonprofits). Implementation. The program engages cross-sector teams through a national retreat, coaching, site visits, interactive webinars, readings, and a community-based action learning project. As of 2020, the program was offered to nine cohorts, serving more than 100 communities across the United States. Results. Results from a mixed-methods evaluation found that high proportions of participants reported increased leadership skills, cross-sector collaboration, continued use of tools and concepts, and positive impact on their communities after participating in the program. Across all cohorts, participants rated themselves on five leadership domains and 17 leadership competencies focused on by the program. All domains and all competencies had statistically significant improvements from the beginning to the end of their program year. Discussion. The improvements in leadership skills were seen across all cohorts, geographies, roles, and sectors. The success of the program suggests the need for leadership programs that emphasize adaptive and collaborative leadership to advance community health and equity.

Tailoring a Text Messaging and Fotonovela Program to Increase Patient Engagement in Colorectal Cancer Screening in a Large Urban Community Clinic Population: Quality Improvement Project.

BACKGROUND: Appropriate annual screenings for colorectal cancer (CRC) are an essential preventive measure for the second-leading cause of cancer-related death in the United States. Studies have shown that CRC screening rates are influenced by various social determinants of health (SDOH) factors, including race, ethnicity, and geography. According to 2018 national data, participation in screening is lowest among Hispanic or Latinx individuals (56.1%). At an urban Federally Qualified Health Center, a quality improvement project was conducted to evaluate a texting program with a motivational fotonovela-a short narrative comic. Fotonovelas have previously been used in programs to improve knowledge of cervical cancer and human papillomavirus, vaccinations, and treatments for depression. OBJECTIVE: This study aimed to encourage compliance with fecal immunochemical test (FIT) screening. Patient engagement involved a texting program with fotonovelas informed by behavior change techniques. This study sought to understand the qualitative characteristics of patient motivation, intention, and barriers to completing their screening. METHODS: A total of 5241 English-speaking or Spanish-speaking Federally Qualified Health Center patients aged 50 to 75 years were randomized to either intervention (a 4-week tailored 2-way texting program with a fotonovela comic) or usual care (an SMS text message reminder and patient navigator phone call). The texting vendor used a proprietary algorithm to categorize patients in the intervention group into SDOH bands based on their home addresses (high impact=high social needs and low impact=low social needs). Over 4 weeks, patients were texted questions about receiving and returning their FIT, what barriers they may be experiencing, and their thoughts about the fotonovela. RESULTS: The SDOH index analysis showed that most of the patient population was in the SDOH band categories of high impact (555/2597, 21.37%) and very high impact (1416/2597, 54.52%). Patients sent 1969 total responses to the texting system. Thematic analysis identified 3 major themes in these responses: messages as a reminder, where patients reported that they were motivated to return the FIT and had already done so or would do so as soon as possible; increasing patients' understanding of screening importance, where patients expressed an increased knowledge about the purpose and importance of the FIT; and expressing barriers, where patients shared reasons for not completing the FIT. CONCLUSIONS: The texting program and fotonovela engaged a subset of patients in each SDOH band, including the high and very high impact bands. Creating culturally tailored messages can encourage patient engagement for accepting the content of the messaging, confirming intentions to complete their FIT, and sharing insights about barriers to behavior change. To better support all patients across the continuum of care with CRC screening, it is important to continue to develop and assess strategies that engage patients who did not return their home-mailed FIT.

Using Text Messages and Fotonovelas to Increase Return of Home-Mailed Colorectal Cancer Screening Tests: Mixed Methods Evaluation.

BACKGROUND: Colorectal cancer (CRC) is currently the second leading cause of cancer-related deaths in the United States; however, it is mostly preventable with appropriate screening and is often treatable when detected at early stages. Many patients enrolled in an urban Federally Qualified Health Center (FQHC) clinic were found to be past due for CRC screening. OBJECTIVE: This study described a quality improvement (QI) project to improve CRC screening rates. This project used bidirectional texting with fotonovela comics and natural language understanding (NLU) to encourage patients to mail fecal immunochemical test (FIT) kits back to the FQHC. METHODS: The FQHC mailed FIT kits to 11,000 unscreened patients in July 2021. Consistent with the usual care, all patients received 2 text messages and a patient navigator call within the first month of mailing. As part of a QI project, 5241 patients who did not return their FIT kit within 3 months, aged 50-75 years, and spoke either English or Spanish were randomized to either usual care (no further intervention) or intervention (4-week texting campaign with a fotonovela comic and remailing kits if requested) groups. The fotonovela was developed to address known barriers to CRC screening. The texting campaign used NLU to respond to patients' texts. A mixed methods evaluation used data from SMS text messages and electronic medical records to understand the impact of the QI project on CRC screening rates. Open-ended text messages were analyzed for themes, and interviews were completed with a convenience sample of patients to understand barriers to screening and impact of the fotonovela. RESULTS: Of the 2597 participants, 1026 (39.5%) in the intervention group engaged with bidirectional texting. Participating in bidirectional texting was related to language preference (χ22=11.0; P=.004) and age group (χ22=19.0; P<.001). Of the 1026 participants who engaged bidirectionally, 318 (31%) clicked on the fotonovela. Furthermore, 54% (32/59) of the patients clicked on the fotonovela and responded that they loved it, and 36% (21/59) of patients responded that they liked it. The intervention group was more likely to get screened (487/2597, 18.75%) than those in usual care (308/2644, 11.65%; P<.001), and this pattern held, regardless of demographic subgroup (sex, age, screening history, preferred language, and payer type). Interview data (n=16) indicated that the text messages, navigator calls, and fotonovelas were well received and not unduly invasive. Interviewees noted several important barriers to CRC screening and offered suggestions for reducing barriers and increasing screening. CONCLUSIONS: Texting using NLU and fotonovela is valuable in increasing CRC screening as observed by the FIT return rate for patients in the intervention group. There were patterns in which patients did not engage bidirectionally; future work should investigate how to ensure that populations are not left out of screening campaigns.

Patient and Clinician Perspectives of a Standardized Question About Firearm Access to Support Suicide Prevention: A Qualitative Study.

Importance: US residents report broad access to firearms, which are the most common means of suicide death in the US. Standardized firearm access questions during routine health care encounters are uncommon despite potential benefits for suicide prevention. Objective: To explore patient and clinician experiences with a standard question about firearm access on a self-administered mental health questionnaire routinely used prior to primary care and mental health specialty encounters. Design, Setting, and Participants: Qualitative semistructured interviews were conducted from November 18, 2019, to October 8, 2020, at Kaiser Permanente Washington, a large integrated care delivery system and insurance provider. Electronic health record data identified adult patients with a documented mental health diagnosis who had received a standard question about firearm access ("Do you have access to guns? yes/no") within the prior 2 weeks. A stratified sampling distribution selected 30% who answered "yes," 30% who answered "no," and 40% who left the question blank. Two groups of clinicians responsible for safety planning with patients at risk of suicide were also sampled: (1) licensed clinical social workers (LICSWs) in primary and urgent care settings and (2) consulting nurses (RNs). Main Outcomes and Measures: Participants completed semistructured telephone interviews, which were recorded and transcribed. Directive (deductive) and conventional (inductive) content analyses were used to apply knowledge from prior research and describe new information. Thematic analysis was used to organize key content, and triangulation was used to describe the intersections between patient and clinician perspectives. Results: Thirty-six patients were interviewed (of 76 sampled; mean [SD] age, 47.3 [17.9] years; 19 [53%] were male; 27 [75%] were White; 3 [8%] were Black; and 1 [3%] was Latinx or Hispanic. Sixteen participants had reported firearm access and 15 had reported thoughts of self-harm on the questionnaire used for sampling. Thirty clinicians were interviewed (of 51 sampled) (mean [SD] age, 44.3 [12.1] years; 24 [80%] were female; 18 [60%] were White; 5 [17%] were Asian or Pacific Islander; and 4 [13%] were Latinx or Hispanic) including 25 LICSWs and 5 RNs. Key organizing themes included perceived value of standardized questions about firearm access, challenges of asking and answering, and considerations for practice improvement. Clinician interview themes largely converged and/or complemented patient interviews. Conclusions and Relevance: In this qualitative study using semistructured interviews with patients and clinicians, a standardized question about firearm access was found to encourage dialogue about firearm access. Respondents underscored the importance of nonjudgmental acknowledgment of patients' reasons for firearm access as key to patient-centered practice improvement.

Self-reported Access to Firearms Among Patients Receiving Care for Mental Health and Substance Use.

Importance: Firearms are the most common method of suicide, one of the "diseases of despair" driving increased mortality in the US over the past decade. However, routine standardized questions about firearm access are uncommon, particularly among adult populations, who are more often asked at the discretion of health care clinicians. Because standard questions are rare, patterns of patient-reported access are unknown. Objective: To evaluate whether and how patients self-report firearm access information on a routine mental health monitoring questionnaire and additionally to examine sociodemographic and clinical associations of reported access. Design Setting and Participants: Cross-sectional study of patients receiving care for mental health and/or substance use in primary care or outpatient mental health specialty clinics of Kaiser Permanente Washington, an integrated health insurance provider and care delivery system. Main Outcomes and Measures: Electronic health records were used to identify patients who completed a standardized self-reported mental health monitoring questionnaire after a single question about firearm access was added from January 1, 2016, through December 31, 2019. Primary analyses evaluated response (answered vs not answered) and reported access (yes vs no) among those who answered, separately for patients seen in primary care and mental health. These analyses also evaluated associations between patient characteristics and reported firearm access. Data analysis took place from February 2020 through May 2021. Results: Among patients (n = 128 802) who completed a mental health monitoring questionnaire during the study period, 74.4% (n = 95 875) saw a primary care clinician and 39.3% (n = 50 631) saw a mental health specialty clinician. The primary care and mental health samples were predominantly female (63.1% and 64.9%, respectively) and White (75.7% and 77.0%), with a mean age of 42.8 and 51.1 years. In primary care, 83.4% of patients answered the question about firearm access, and 20.9% of patients who responded to the firearm question reported having access. In mental health, 91.8% of patients answered the question, and 15.3% reported having access. Conclusions and Relevance: In this cross-sectional study of adult patients receiving care for mental health and substance use, most patients answered a question about firearm access on a standardized mental health questionnaire. These findings provide a critical foundation to help advance understanding of the utility of standardized firearm access assessment and to inform development of practice guidelines and recommendations. Responses to standard firearm access questions used in combination with dialogue and decision-making resources about firearm access and storage may improve suicide prevention practices and outcomes.

The Ability of Practices to Report Clinical Quality Measures: More Evidence of the Size Paradox?

PURPOSE: To assess whether primary care practices with and without support from a larger organization differ in their ability to produce timely reports on cardiovascular disease quality measures. BACKGROUND: Although many primary care practices are now part of larger organizations, it is not clear whether such a shift will improve the ability of those who work in these primary care settings to easily access and use their own data for improvement. METHODS: Smaller primary care practices were enrolled in a trial of external practice support to build quality improvement (QI) capacity. A request for clinical quality measure (eCQM) data were sent to each practice and study outcomes were defined based on the date on which practices first submitted valid data for at least 1 of the 3 measures. A practice survey completed by a clinic manager captured practice characteristics, including the presence of QI support from a larger organization. RESULTS: Of the 209 enrolled practices, 205 had complete data for analysis. Practices without central QI support had higher rates of eCQM submission at 30 days (38% vs 20%) and 60 days, (63% vs 48%) than practices with central QI support. Practices with central QI support took longer to submit data (median, 57 days) compared with practices without centralized support (median, 40 days) although this difference was not significant. CONCLUSION: The ability of smaller practices without centralized QI support to report their eCQMs more quickly may have implications for their subsequent ability to improve these measures.

The association between sugar-sweetened beverage availability in school vending machines and school staff sugar-sweetened beverage consumption.

Reducing sugar-sweetened beverage (SSB) consumption is a leading strategy to help combat high rates of adult obesity and overweight. Regulating SSB sales in schools has reduced access among youth. However, current federal school nutrition standards are focused on student rather than staff environments (i.e. school staff lounges). This study examines the association between the availability of SSBs in school vending machines and school staff SSB consumption. The study sample included 51 public schools in California, Oregon, Washington, Maryland, and Washington DC participating in an evaluation of Kaiser Permanente's Thriving Schools initiative in school year 2017-18. Data collection included: 1) observations of school cafeterias, staff lounges, stores and outdoor snack areas for the presence of, and content in, vending machines, and 2) an online survey of school staff about their SSB consumption. Fifty-nine percent (n = 1586) of staff responded to the survey; 1229 (77% of respondents) reported on SSB consumption. Thirty percent of schools had staff lounges with SSB vending machines and 34% of staff reported drinking ≥1 SSBs/day. On average, the probability of consuming ≥1 SSBs/day was 6.6% greater in staff in schools with SSBs available in staff lounge vending machines (95% CI: 0.11%, 13.12%). Staff in schools with SSB vending machines in staff lounges were more likely to report consuming ≥1 SSBs per day compared to staff without SSB vending in staff lounges. Examining the impact of extending SSB regulations to the entire school environment on school staff SSB consumption is an important next step.

Dose as a Tool for Planning and Implementing Community-Based Health Strategies.

A major challenge in community-based health promotion is implementing strategies that could realistically improve health at the population level. Population dose methodology was developed to help understand the combined impact of multiple strategies on population-level health behaviors. This paper describes one potential use of dose: as a tool for working collaboratively with communities to increase impact when planning and implementing community-level initiatives. Findings are presented from interviews conducted with 11 coordinators who used dose for planning and implementing local efforts with community coalitions. During early-stage planning, dose was used as a tool for strategic planning, and as a framework to build consensus among coalition partners. During implementation, a dose lens was used to revise strategies to increase their reach (the number of people exposed to the intervention) or strength (the relative change in behavior for each exposed person) to create population-level impact. A case study is presented, illustrating how some community coalitions and evaluators currently integrate dose into the planning and implementation of place-based healthy eating and active living strategies. Finally, a planning checklist was developed for program coordinators and evaluators. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Using Population Dose to Evaluate Community-level Health Initiatives.

Successful community-level health initiatives require implementing an effective portfolio of strategies and understanding their impact on population health. These factors are complicated by the heterogeneity of overlapping multicomponent strategies and availability of population-level data that align with the initiatives. To address these complexities, the population dose methodology was developed for planning and evaluating multicomponent community initiatives. Building on the population dose methodology previously developed, this paper operationalizes dose estimates of one initiative targeting youth physical activity as part of the Kaiser Permanente Community Health Initiative, a multicomponent community-level obesity prevention initiative. The technical details needed to operationalize the population dose method are explained, and the use of population dose as an interim proxy for population-level survey data is introduced. The alignment of the estimated impact from strategy-level data analysis using the dose methodology and the data from the population-level survey suggest that dose is useful for conducting real-time evaluation of multiple heterogeneous strategies, and as a viable proxy for existing population-level surveys when robust strategy-level evaluation data are collected. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Increase in Physical Activity Sustained 1 Year After Playground Intervention.

INTRODUCTION: Regular physical activity is a vital component of child health, and schools play an important role in the promotion of physical activity among children. This paper describes the implementation and evaluation of a playground redesign involving structural and loose play equipment to increase students' physical activity at an intermediate school in Leadville, Colorado. METHODS: Direct observations were conducted during recess before the redesign in May 2014, then again at 6 months and 1 year after the redesign. During each observation, observers scanned the playground and counted how many students were sedentary, engaged in moderate activity, or engaged in vigorous activity. System for Observing Play and Leisure Activity in Youth, a validated instrument for observing physical activity in free play settings, was used to collect observation data. RESULTS: Six months from baseline, the percentage of children engaging in moderate to vigorous physical activity during recess increased by 23.3%, and the percentage engaged in vigorous physical activity increased by 26.2%. These increases were sustained at 1 year from baseline, with an increase of 17.2% for moderate to vigorous physical activity and 33.1% for vigorous physical activity. Chi-square tests of independence showed that changes in the proportion of students engaging in moderate to vigorous physical activity and vigorous physical activity were statistically significant (p<0.01). CONCLUSIONS: This evaluation demonstrated that environmental interventions involving the provision of structural and loose play equipment can be implemented in an intermediate school setting, and can create a sustainable increase in physical activity among students during recess. This example also demonstrates that schools and community organizations can evaluate the impact of these interventions using relatively simple, low-cost observational methods. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Boulder Food Rescue: An Innovative Approach to Reducing Food Waste and Increasing Food Security.

Food waste and food insecurity are both significant issues in communities throughout the U.S., including Boulder, Colorado. As much as 40% of the food produced in the U.S. goes uneaten and ends up in landfills. Nearly 13% of people in the Boulder region experience some level of food insecurity. Founded in 2011, Boulder Food Rescue supports community members to create their own food security through a participatory approach to an emergency food system. The organization uses a web-application "robot" to manage a schedule of volunteers. They coordinate with individuals at low-income senior housing sites, individual housing sites, family housing sites, after-school programs, and pre-schools to set up no-cost grocery programs stocked with food from local markets and grocers that would otherwise go to waste. Each site coordinator makes decisions about how, when, and where food delivery and distribution will occur. The program also conducts robust, real-time data collection and analysis. Boulder Food Rescue is a member and manager of the Food Rescue Alliance, and its model has been replicated and adapted by other cities, including Denver, Colorado Springs, Seattle, Jackson Hole, Minneapolis, Binghamton, and in the Philippines. Information for this special article was collected through key informant interviews with current and former Boulder Food Rescue staff and document review of Boulder Food Rescue materials. Boulder Food Rescue's open source software is available to other communities; to date, 40 cities have used the tool to start their own food rescue organizations. Boulder Food Rescue hopes to continue spreading this model to other cities that are considering ways to reduce food waste and increase food security. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

A Community-Level Initiative to Prevent Obesity: Results From Kaiser Permanente's Healthy Eating Active Living Zones Initiative in California.

INTRODUCTION: A growing number of health systems are leading health promotion efforts in their wider communities. What impact are these efforts having on health behaviors and ultimately health status? This paper presents evaluation results from the place-based Kaiser Permanente Healthy Eating Active Living Zones obesity prevention initiative, implemented in 2011-2015 in 12 low-income communities in Kaiser Permanente's Northern and Southern California Regions. METHODS: The Healthy Eating Active Living Zones design targeted places and people through policy, environmental, and programmatic strategies. Each Healthy Eating Active Living Zone is a small, low-income community of 10,000 to 20,000 residents with high obesity rates and other health disparities. Community coalitions planned and implemented strategies in each community. A population-dose approach and pre and post surveys were used to assess impact of policy, program, and environmental change strategies; the analysis was conducted in 2016. Population dose is the product of reach (number of people affected by a strategy divided by target population size) and strength (the effect size or relative change in behavior for each person exposed to the strategy). RESULTS: More than 230 community change strategies were implemented over 3 years, encompassing policy, environmental, and programmatic changes as well as efforts to build community capacity to sustain strategies and make changes in the future. Positive population-level results were seen for higher-dose strategies, particularly those targeting youth physical activity. Higher-dose strategies were more likely to be found in communities with the longest duration of investment. CONCLUSIONS: These results demonstrate that strong (high-dose), community-based obesity prevention strategies can lead to improved health behaviors, particularly among youth in school settings. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Changes in Nutrition Policies and Dietary Intake in Child Care Homes Participating in Healthy Eating and Active Living Initiative.

INTRODUCTION: From 2012 to 2014, a total of 17 family child care homes participated in a multisector, community-wide initiative to prevent obesity. Strategies included staff workshops, materials, site visits, and technical assistance regarding development and implementation of nutrition policies. The purpose of the evaluation was to examine the impact of the initiative on family child care home nutrition-related policies and practices and child dietary intake. STUDY DESIGN: Pre- and post-intervention without control group. Measures taken at baseline and follow-up included structured observations and questionnaires regarding nutrition policies, practices, and environments; documentation of lunch foods served on 5 days; and lunch plate waste observations on 2 days. Paired t-tests were used to determine the significance of change over time. SETTING/PARTICIPANTS: Seventeen family child care homes in a low-income diverse community in Northern California; children aged 2-5 years who attended the family child care homes. MAIN OUTCOME MEASURES: Change in nutrition-related policies and practices, lunch foods served and consumed. RESULTS: Data was collected at 17 sites for an average of 5.2 children aged 2-5 years per site per day at baseline and 4.6 at follow-up for a total of 333 plate waste observations. There were significant increases in staff training, parental involvement, and several of the targeted nutrition-related practices; prevalence of most other practices either improved or was maintained over time. There were significant increases in the number of sites meeting Child and Adult Care Food Program meal guidelines, variety of fruit and frequency of vegetables offered, and reductions in frequency of juice and high-fat processed meats offered. Adequate portions of all food groups were consumed at both time points with no significant change over time. CONCLUSIONS: A simple, policy-focused intervention by a child care resource and referral agency was successful at reinforcing and improving upon nutrition-related practices at family child care homes. Children consumed adequate, but not excessive, portions of the balanced meals served to them, suggesting there is no reason to offer unhealthy options. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Changes in Consumer Purchases in Stores Participating in an Obesity Prevention Initiative.

INTRODUCTION: From 2011 to 2014, small stores in three communities participated in a community-wide obesity prevention initiative. The study aimed to determine how participation in the initiative influenced store environments and consumer purchases. STUDY DESIGN: Pre- and post-intervention without control. Structured observations of the store environments and intercept surveys of adult shoppers at all stores, and of children at two stores, conducted at baseline and follow-up. Manager/owner interviews regarding perceived impacts of the intervention conducted at follow-up. SETTING/PARTICIPANTS: Shoppers at nine small stores in three diverse, low-income communities in Northern California. INTERVENTION: The store interventions were determined locally with combinations of strategies such as product displays, healthier options, marketing and promotion, store layout, and facility improvements that were implemented to varying degrees at each site. MAIN OUTCOME MEASURES: Changes in store environments and purchases of select foods and beverages. RESULTS: Stores experienced consistent, but not always significant, declines in purchases of sweets and chips and increases in purchases of fruits and vegetables at select stores. Decreases in purchases of targeted sugar-sweetened beverages were offset by increases in purchases of other sugar-sweetened beverages. Changes in store environments and promotional activities varied widely from store to store and corresponded to variations in changes in purchasing. The owners/managers perceived benefits to their bottom line and community/customer relations, but challenges were identified that may account for the varied degree of implementation. CONCLUSIONS: Substantive improvements in fruit and vegetable availability and promotion were needed to achieve a measurable impact on purchases but reducing purchases of unhealthy foods, like sweets and chips, required a less consistent intensive effort. These findings suggest it may be challenging to achieve the consistent and targeted implementation of changes and ongoing promotional efforts at a large enough proportion of stores where residents shop that would be required to get measurable impacts at the community level. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Improvements in Physical Activity Opportunities: Results From a Community-Based Family Child Care Intervention.

INTRODUCTION: Reaching preschool-aged children to establish healthy lifestyle habits, including physical activity, is an important component of obesity prevention efforts. However, few studies have examined family child care homes where nearly 1 million children receive care. STUDY DESIGN: A pre- and post-intervention evaluation without a control group was conducted to evaluate what changes occurred in family child care homes that participated in the Healthy Eating and Active Living project, a multicomponent obesity prevention initiative, focused on community-driven policy and environmental change in neighborhoods within Kaiser Permanente service areas. SETTING/PARTICIPANTS: From 2012 to 2014, a total of 17 family child care homes in Northern California participated in the intervention. INTERVENTION: A physical activity workshop for child care staff and technical assistance to develop a policy to promote physical activity and other healthy behaviors. MAIN OUTCOME MEASURES: Pre and post observations, questionnaires, and physical activity logs were completed to assess change in physical activity resources available in the family child care homes, the amount of child screen time offered, type and amount of physical activity offered to children, and implementation of physical activity best practices. RESULTS: Between baseline and follow-up, providers significantly increased both the number of structured, adult-led activities (2.6 vs 3.2 activities per day) and the number of structured, adult-led minutes of activity in which children participated (49 vs 83 minutes per day). Providers also improved screen time practices and made improvements to the physical activity environment. CONCLUSIONS: In this study, a community-based organization designed and implemented multicomponent strategies tailored for participating family child care homes. The successful implementation of the intervention likely contributed to implementation of practices that increased opportunities for physical activity for the young children attending these family child care homes. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Family history of diabetes and pancreatic cancer as risk factors for pancreatic cancer: the PACIFIC study.

Genetic association studies have identified more than a dozen genes associated with risk of pancreatic cancer. Given this genetic heterogeneity, family history can be useful for identifying individuals at high risk for this disease. The goal of this analysis was to evaluate associations of family history of diabetes and family history of pancreatic cancer with risk of pancreatic cancer. PACIFIC is a case-control study based on two large health plans. Cases were diagnosed with pancreatic ductal adenocarcinoma (PDA) and controls were selected from the health plan enrollment databases and frequency matched to cases. Family history data were collected using an interviewer-administered questionnaire and were available on 654 cases and 697 controls. Logistic regression was used for the association analyses. First-degree relative history of diabetes was statistically significantly associated with increased risk of PDA [OR, 1.37; 95% confidence interval (CI), 1.10-1.71]. The highest risk of PDA was observed for an offspring with diabetes (OR, 1.95; 95% CI, 1.23-3.09). In addition, history of pancreatic cancer increased risk for PDA with an OR of 2.79 (95% CI, 1.44-4.08) for any first-degree relative history of pancreatic cancer. This population-based analysis showed that family history of diabetes was associated with increased risk of PDA and confirmed previous studies showing that first-degree family history of pancreatic cancer is associated with PDA. These results support the need for ongoing studies of genetic influences on pancreatic cancer in large samples and investigations of possible pleiotropic genetic effects on diabetes and pancreatic cancer.

How to identify students for school-based depression intervention: can school record review be substituted for universal depression screening?

PROBLEM: Early identification and intervention are critical for reducing the adverse effects of depression on academic and occupational performance. Cost-effective approaches are needed for identifying adolescents at high depression risk. This study evaluated the utility of school record review versus universal school-based depression screening for determining eligibility for an indicated depression intervention program implemented in the middle school setting. METHODS: Algorithms derived from grades, attendance, suspensions, and basic demographic information were evaluated with regard to their ability to predict students' depression screening scores. FINDINGS: The school information-based algorithms proved poor proxies for individual students' depression screening results. However, school records showed promise for identifying low, medium, and high-yield subgroups on the basis of which efficient screening targeting decisions could be made. CONCLUSIONS: Study results will help to guide school nurses who coordinate indicated depression intervention programs in school settings as they evaluate options of approaches for determining which students are eligible for participation.

Cost-effectiveness of a school-based emotional health screening program.

BACKGROUND: School-based screening for health conditions can help extend the reach of health services to underserved populations. Screening for mental health conditions is growing in acceptability, but evidence of cost-effectiveness is lacking. This study assessed costs and effectiveness associated with the Developmental Pathways Screening Program, in which students undergo universal classroom emotional health screening and those who have positive screens are provided with on-site clinical evaluation and referral. METHODS: Costs are enumerated for screening and clinical evaluation in terms of labor and overhead and summarized as cost per enrolled student, per positive screen, and per referral. Cost-effectiveness is summarized as cost per student successfully linked to services. School demographics are used to generate a predictive formula for estimating the proportion of students likely to screen positive in a particular school, which can be used to estimate program cost. RESULTS: Screening costs ranged from $8.88 to $13.64 per enrolled student, depending on the prevalence of positive screens in a school. Of students referred for services, 72% were linked to supportive services within 6 weeks. Cost-effectiveness was estimated to be $416.90 per successful linkage when 5% screened positive and $106.09 when 20% screened positive. A formula to estimate the proportion of students screening positive proved accurate to within 5%. CONCLUSION: Information concerning costs and effectiveness of school-based emotional health screening programs can guide school districts in making decisions concerning resource allocation.