Supporting Stabilization: A Qualitative Evaluation of a Pilot Program to Integrate Personal Caregiving Services Into Housing Settings.

Three organizations in Clark County, WA, partnered together to implement a pilot program to expand access to personal caregiving services in the homeless crisis response system. The aim of this study is to describe staff and clients' experiences of the program and its impact on clients' daily living activities, health and wellbeing, and housing stability. Using a qualitative descriptive design, semi-structured, in-depth interviews were conducted with 12 clients and 5 pilot staff, representing 4 housing service providers. Interviews were analyzed descriptively to examine staff and clients' perspectives and experiences with the personal care services pilot program. Caregivers helped clients establish routines, find companionship, and connect to health and social services both logistically and socioemotionally, supporting clients' stabilization and reducing barriers to healthcare. Hiring and retaining caregivers remained difficult due to the challenging nature of the work. Staff interviews highlight the need for additional supports to better retain caregivers. Findings from the evaluation have important implications for addressing the needs of individuals exiting homelessness and suggest that personal caregivers can play an important role in supporting the stabilization process. However, employing strategies such as training and increasing wages and benefits that support the needs of the caregiving workforce is essential to sustain this type of service delivery model.

Assessing the impact of recovery housing on healthcare utilization in Portland, Oregon.

Introduction: Central City Concern (CCC) operates several recovery housing sites in the Portland, Oregon metropolitan region, including the Blackburn Center (Blackburn) and the Richard L. Harris Building (Harris). This retrospective, observational study was designed to assess recovery housing's impact on inpatient detoxification readmission rates and healthcare utilization patterns. Methods: Our study population consisted of individuals discharged from CCC's Hooper Detox Stabilization Center from June 2019 to September 2020. A total of 75 clients housed at Blackburn, 63 clients housed at Harris, and 57 clients discharged as unhoused were included in the study sample. Using logistic regression for each of the two recovery housing groups relative to the unhoused group, we examined differences in readmissions to inpatient detoxification after their qualifying discharge. We then used Difference-In-Difference model to compare the per member per year (PMPY) use of different domains of health care before and after their qualifying discharge. Results: Compared to clients discharged as unhoused, Blackburn and Harris residents had lower risk of readmissions to inpatient detoxification treatment at 90- and 180-days post-discharge. Additionally, while the mean number of PMPY emergency department visits increased for clients discharged as unhoused in the post period, the average number of emergency department visits decreased for clients who obtained recovery housing at Blackburn (DiD=-3.65 PMPY, p-value=0.02) and at Harris (DiD=-3.87 PMPY, p-value=0.01). Conclusion: Findings highlight the impact and importance of recovery housing for individuals managing a substance use disorder and the value of healthcare system and public sector investment housing like Blackburn and Harris.

Evaluation of an Integrated Intervention to Address Clinical Care and Social Needs Among Patients with Type 2 Diabetes.

BACKGROUND: The Providence Diabetes Collective Impact Initiative (DCII) was designed to address the clinical challenges of type 2 diabetes and the social determinants of health (SDoH) challenges that exacerbate disease impact. OBJECTIVE: We assessed the impact of the DCII, a multifaceted intervention approach to diabetes treatment that employed both clinical and SDoH strategies, on access to medical and social services. DESIGN: The evaluation employed a cohort design and used an adjusted difference-in-difference model to compare treatment and control groups. PARTICIPANTS: Our study population consisted of 1220 people (740 treatment, 480 control), aged 18-65 years old with a pre-existing type 2 diabetes diagnosis who visited one of the seven Providence clinics (three treatment and four control) in the tri-county area of Portland, Oregon, between August 2019 and November 2020. INTERVENTIONS: The DCII threaded together clinical approaches such as outreach, standardized protocols, and diabetes self-management education and SDoH strategies including social needs screening, referral to a community resource desk, and social needs support (e.g., transportation) to create a comprehensive, multi-sector intervention. MAIN MEASURES: Outcome measures included SDoH screens, diabetes education participation, HbA1c, blood pressure, and virtual and in-person primary care utilization, as well as inpatient and emergency department hospitalization. KEY RESULTS: Compared to patients at the control clinics, patients at DCII clinics saw an increase in diabetes education (15.5%, p<0.001), were modestly more likely to receive SDoH screening (4.4%, p<0.087), and had an increase in the average number of virtual primary care visits of 0.35 per member, per year (p<0.001). No differences in HbA1c, blood pressure, or hospitalization were observed. CONCLUSIONS: DCII participation was associated with improvements in diabetes education use, SDoH screening, and some measures of care utilization.

Participant Perspectives on Community Health Workers' Critical Role in Their Experience of the Pathways Program to Address Complex Needs.

This study aimed to describe participants' experiences of Pathways, a community hub care coordination model, including its impact on their lives and their relationship with the Pathways community health worker (CHW). The research team conducted semistructured, in-depth interviews with Pathways participants (n = 13) and analyzed interviews using thematic analysis. Interviews reveal how Pathways helps individuals navigate systems more confidently, increases access to needed resources, and improves well-being. CHWs defined participants' experience, providing a safe, reliable setting to make progress toward goals. Our findings support the evidence base for Pathways as an effective model of care coordination for people with complex needs.

The Role of Community Health Workers in Developing Multidimensional Organizational Relationships.

Effective care coordination relies on organizations working collaboratively to meet medically and socially complex participants' needs. This study examines community health workers' (CHWs') roles in developing the organizational relationships on which care coordination efforts depend. Semistructured interviews (n = 13) were conducted with CHWs, CHWs' supervisors, and executive staff at organizations participating in a Washington State care coordination program. Interviewees described how CHWs developed and furthered multidimensional relationships in service of participants between and within participating organizations, as well as external organizations. Relationship-building challenges included COVID-19, geographic context, and staffing. The study concludes with considerations for care coordination efforts to support CHWs.

Differences in access to virtual and in-person primary care by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system.

BACKGROUND: Research exploring telehealth expansion during the COVID-19 pandemic has demonstrated that groups disproportionately impacted by COVID-19 also experience worse access to telehealth. However, this research has been cross-sectional or short in duration; geographically limited; has not accounted for pre-existing access disparities; and has not examined COVID-19 patients. We examined virtual primary care use by race/ethnicity and community social vulnerability among adults diagnosed with COVID-19 in a large, multi-state health system. We also assessed use of in-person primary care to understand whether disparities in virtual access may have been offset by improved in-person access. METHODS: Using a cohort design, electronic health records, and Centers for Disease Control and Prevention Social Vulnerability Index, we compared changes in virtual and in-person primary care use by race/ethnicity and community social vulnerability in the year before and after COVID-19 diagnosis. Our study population included 11,326 adult patients diagnosed with COVID-19 between March and July 2020. We estimated logistic regression models to examine likelihood of primary care use. In all regression models we computed robust standard errors; in adjusted models we controlled for demographic and health characteristics of patients. RESULTS: In a patient population of primarily Hispanic/Latino and non-Hispanic White individuals, and in which over half lived in socially vulnerable areas, likelihood of virtual primary care use increased from the year before to the year after COVID-19 diagnosis (3.6 to 10.3%); while in-person use remained stable (21.0 to 20.7%). In unadjusted and adjusted regression models, compared with White patients, Hispanic/Latino and other race/ethnicity patients were significantly less likely to use virtual care before and after COVID-19 diagnosis; Hispanic/Latino, Native Hawaiian/Pacific Islander, and other race/ethnicity patients, and patients living in socially vulnerable areas were also significantly less likely to use in-person care during these time periods. CONCLUSIONS: Newly expanded virtual primary care has not equitably benefited individuals from racialized groups diagnosed with COVID-19, and virtual access disparities have not been offset by improved in-person access. Health systems should employ evidence-based strategies to equitably provide care, including representative provider networks; targeted, empowering outreach; co-developed culturally and linguistically appropriate tools and technologies; and provision of enabling resources and services.

Differences in Outpatient Health Care Utilization 12 Months after COVID-19 Infection by Race/Ethnicity and Community Social Vulnerability.

Ensuring access to high-quality outpatient care is an important strategy to improve COVID-19 outcomes, reduce social inequities, and prevent potentially expensive complications of disease. This study assesses the equity of health care response to COVID-19 by examining outpatient care utilization by factors at the individual and community levels in the 12 months prior to and following COVID-19 diagnosis. Employing a retrospective, observational cohort design, we analyzed electronic health record data from a sample of 11,326 adults diagnosed with COVID-19 between March and July 2020. We used two-part models to estimate changes in use of primary and specialty care by race/ethnicity and community social vulnerability in the year before and after COVID-19 diagnosis. Our findings showed that while overall probability and counts of primary and specialty care visits increased following a positive COVID-19 diagnosis, disparities in care utilization by race/ethnicity and living in a socially vulnerable community persisted in the year that followed. These findings reiterate the need for strategic approaches to improve access to and utilization of care among those diagnosed with COVID-19, especially for individuals who are traditionally undeserved by the health system. Our findings also highlight the importance of systematic approaches for addressing social inequity in health care.

Health and Health Care Use Strongly Associated with Cumulative Burden of Social Determinants of Health.

Understanding health outcomes and patterns of health care utilization associated with patients' cumulative social determinant of health (SDOH) risk is essential to supporting better health care. This study compared mental and physical health outcomes and health care utilization by increasing number of social needs among a clinical adult population. Surveys were sent to 6000 patients with recent visits to 7 primary care clinics in Portland, Oregon in 2018. The final study sample included respondents who matched to medical claims data, N = 1748. The authors used a modified logistic regression model to estimate risk ratios for the relationship between cumulative SDOH factors and self-reported chronic conditions, and a 2-part model to estimate the effects of cumulative SDOH risk on health care utilization. Increased SDOH need was associated with increasing likelihood of worse self-reported health outcomes, especially mental health. Compared with those with no SDOH need, having 1-2 SDOH need(s) (adjusted risk ratio [aRR] 1.25; 95% confidence interval [CI]: 1.06-1.46) and 3 or more SDOH needs (aRR 1.45; 95% CI: 1.22-1.73) had a greater risk of reporting any behavioral health condition. However, the number of SDOH had a graded but inverse impact on use of mental health care services where fewer visits were observed among those using care. Having SDOH was associated with increased likelihood of having an emergency department visit and increased number of primary care visits. This study demonstrates the compounding impact of SDOH on health and health care use. This highlights the importance of collecting SDOH, including the total number of SDOH needs, when considering a patient's health and health care.

Exploring the Relationship Between MyPlate Knowledge, Perceived Diet Quality, and Healthy Eating Behaviors Among Adolescents.

PURPOSE: MyPlate is the current dietary guidance icon meant to communicate healthy eating patterns. The purpose of this study is to evaluate knowledge of MyPlate nutrition education messages among middle school students and its association with dietary intake and perceived diet quality. DESIGN: Secondary analysis of cross-sectional data. SETTINGS: Survey of eighth-grade students from 16 middle schools in California. SUBJECTS: A total of 3521 eighth-grade students. MEASURES: MyPlate knowledge was assessed with 3 questions asking how much of the plate in a typical meal should be (1) fruits and vegetables, (2) grains, and (3) proteins. A brief food frequency questionnaire measured intake of fruits, vegetables, sweets, salty snacks, fast-food, and sugar-sweetened beverages (SSBs) over the past 7 days. Students self-rated their diet quality as poor, fair, good, or excellent. ANALYSIS: Hierarchical logistic regression models controlling for gender, ethnicity, and socioeconomic status. RESULTS: Only 11% of students answered all MyPlate questions correctly. MyPlate knowledge was associated with 65% higher odds of not consuming SSBs, but 46% lower odds of not consuming sweets. MyPlate knowledge was not associated with adolescents' perceived diet quality or intake of salty snacks, fruits, or vegetables. CONCLUSION: Knowledge of nutrition education messages communicated by the MyPlate dietary guidance icon is limited among adolescents. The association between MyPlate knowledge and lower consumption of SSBs is encouraging, given the strong association between SSBs and childhood obesity.

Strategies for Effective Collaboration with Middle School Physical Education Teachers: An Application of School-Engaged Research.

BACKGROUND: Increasing the capacity of teachers to deliver physical education (PE) lessons that are high in moderate to vigorous physical activity (PA) is one strategy to increase the amount of exercise students receive during school. However, traditional research approaches have not directly engaged the school community as equitable partners in the intervention design process. The purpose of this article is to describe the process, outputs, and lessons learned from a school-engaged research study, which incorporates the unique needs of schools-in terms of structure, accountability measures, and array of stakeholders into the research process and design. METHODS: This article describes lessons learned from Project SHAPE, a PA intervention that used principles of school-engaged research to guide program planning, recruitment, implementation, and data dissemination. RESULTS: The study team successfully partnered with 16 schools and enrolled 55 teachers and surveyed 4,773 students. CONCLUSIONS: Efforts to improve PE programs can benefit from a school-engaged research approach that directly involves teachers, fosters mutually beneficial relationships, and integrates the schools' perspective in the research process.

"You Only Teach PE and It Doesn't Really Matter": Middle School PE Teachers' Perspectives on Intervention Efforts to Increase Physical Activity.

Physical education (PE) is a frequent site of public health intervention to promote physical activity (PA); however, intervention research frequently overlooks the perspective of PE teachers. The purpose of this qualitative study was to explore teachers' experiences with and perceptions of a PA curriculum intervention. Six findings within three categories were identified and described in detail. In-depth one-on-one semistructured interviews were conducted with nine PE teachers from eight middle schools in Los Angeles. Feeling underappreciated and having a "muddled mission" within PE were driving factors in teacher morale and practice. Teachers had positive experiences with the curriculum, but significant barriers remained and limited the potential for PA during PE classes. PE teachers are pulled in multiple directions and perceive a lack of necessary support systems to achieve student health goals. Interventions aimed at leveraging PE as a site of PA promotion must incorporate the perspectives of PE teachers.

Evaluation of an Intervention to Increase Physical Activity in Low-Income, Urban Middle Schools.

BACKGROUND: Physical education (PE) can provide opportunities to engage in daily moderate-to-vigorous physical activity (MVPA), but MVPA levels in many classes are low. This study examines MVPA during middle school PE lessons before and after receiving the SPARK (Sports, Play, and Active Recreation for Kids) program. METHODS: Sixteen schools were enrolled in the study. PE teachers at eight schools received the intervention. PE lessons at all schools (N = 561) were observed over 2 years. Hierarchical linear regression models examined the effect of the intervention on the amount and consistency of MVPA and sedentary behavior. RESULTS: An average of 13.7% of observed class time was spent in MVPA (approximately 5 minutes of a 60-minute class), compared to 27.5% of time spent sedentary. There was no evidence that the curriculum resulted in increased MVPA or consistent MVPA, or that it decreased sedentary behavior. Findings also suggested that contextual factors may contribute to physical activity levels in PE. CONCLUSIONS: Mixed evaluation findings of the SPARK middle school curriculum demonstrate that an out-of-the-box curriculum does not have the same results in all contexts. Implications for school health are described based upon findings. Further research is needed to identify effective strategies to increase MVPA for adolescents both in and outside of PE.

The Effects of a 2-Year Middle School Physical Education Program on Physical Activity and Its Determinants.

Purpose: This study examines the effects of the middle school SPARK physical education (PE) curriculum on predisposing, enabling, and reinforcing factors for physical activity (PA) as well as self-reported PA in a predominantly low-income, Latinx student population in Los Angeles, CA. Methods: Data were collected from 3763 students of seventh and eighth grades at 2 time points at the 16 middle schools enrolled in the study. Hierarchical logistic regression models were used to assess intervention effects on PA attitudes, PE enjoyment, FitnessGram passing, daily PA, and muscle-strengthening PA, controlling for demographic variables. Results: Although there was no detectable intervention effect on increasing the number of students exercising 60 minutes per day, there was a negative intervention effect detected for muscle-strengthening exercises. A significant positive intervention effect was detected for both PE enjoyment and FitnessGram passing. Deeper analysis of these findings revealed that the positive effect on PE enjoyment occurred only among male students. Conclusion: The SPARK curriculum had mixed effects on students' PA behavior as well as predisposing, enabling, and reinforcing factors for PA. Incorporating student perspectives into the evaluation of intervention efforts to promote PA can facilitate a better understanding of the ways in which these efforts influence PA behaviors and its determinants.

Weight perception and perceived attractiveness associated with self-rated health in young adults.

Self-rated health (SRH) is a widely used and valid marker of overall health and wellbeing and demographic differences in SRH are well-established. To date, few studies have examined how multiple components of body image shape young adults' SRH. The purpose of this study was to investigate the contributions of weight perception and perceived attractiveness on SRH among young adults. Data were from Wave IV (2007-2008) of the National Longitudinal Study of Adolescent to Adult Health (Add Health) and young women and men ages 24-34 were analyzed (n = 7044 women, n = 6594 men) in April 2018. All analyses were weighted and stratified by gender. Design-based F test and ordinal multinomial logistic regression were used. For both genders, relative to Whites, Hispanic, Black, and Asian young adults reported poorer health; women and men with higher education and income reported better health. Independent of measured body mass index (BMI), young adults who thought they were underweight or overweight reported poorer health relative to those who thought their weight was normal. Both young women and young men who thought they were more attractive also reported better health. This study demonstrates that weight status, perceived weight status, and perceived attractiveness independently impact SRH for both young men and women controlling for race/ethnicity, nativity status, marital status, education, income, and number of health conditions.

Physical Activity Correlates in Middle School Adolescents: Perceived Benefits and Barriers and Their Determinants.

The purpose of this study was to examine the determinants of benefits and barriers and their relationship with physical activity (PA) among predominantly Latino middle school students. Data were collected in a cross-sectional survey of 4,773 seventh-grade students recruited from a large, urban school district in Los Angeles. Hierarchical logistic regression models were used to assess determinants of benefits and barriers as well as their association with self-reported PA. Differences in benefits and barriers were observed by gender, ethnicity, and body size. Barriers were negatively correlated with all three PA outcomes while benefits were positively associated with exercising at least 60 min daily. A deeper understanding of benefits and barriers can facilitate the development of interventions and collaborative efforts among physical education teachers, school nurses, and administrators to implement comprehensive approaches that encourage students' participation in PA inside and outside of the classroom.

Correlates of Social Support and its Association With Physical Activity Among Young Adolescents.

BACKGROUND: A substantial proportion of adolescents, particularly girls and minority youth, fail to meet daily physical activity (PA) recommendations. Social support contributes to adolescent PA, but studies examining this relationship have yielded inconsistent results and rarely focus on diverse, urban populations. AIMS: This study examines the correlates of support for PA from family and friends and its relationship with PA outcomes among young adolescents. METHODS: Data were collected in a cross-sectional survey of 4,773 middle school students. Social support from family and friends was separately measured using the Sallis Support for Exercise Scales. Hierarchical logistic regression models were used to assess correlates of high support and the relationship between support and self-reported PA. RESULTS: Approximately one quarter of students reported being active for at least an hour each day. 31.7% of students reported high family support for PA, while 17.8% reported high friend support. Differences in perceptions of support by gender, ethnicity, and language emerged. Support from family and friends were both consistently strong predictors of all three PA outcomes measured. DISCUSSION: Findings highlight the need for multilevel interventions targeting both psychosocial influences on behavior in addition to addressing the physical environment. Given low rates of friend support for PA, there appears to be an opportunity to increase PA levels through promotion of supportive behaviors among peers. CONCLUSION: Support for PA from family and friends is a key contributor to increased PA among adolescents. Further research is needed to further understand the mechanisms by which these factors influence PA.

Nutrition Campaign Knowledge and Dietary Behavior in Middle School Students.

BACKGROUND: Federal nutrition campaigns are designed to make dietary recommendations accessible but have not been extensively evaluated. This paper explores whether knowledge of nutrition campaigns is associated with dietary behavior among young adolescents. METHODS: Cross-sectional survey data were collected from 4,773 middle school students in Southern California. Hierarchical logistic regression models were used to assess the association between dietary behaviors and nutrition campaign knowledge, controlling for gender and ethnicity. RESULTS: Knowledge of the Fruit & Veggies-More Matters campaign was associated with increased odds of high fruit and vegetable consumption, knowledge of the MyPlate campaign was associated with neither, and both were associated with increased odds of not consuming soda. CONCLUSION: Overall, low percentages of students demonstrated knowledge of nutrition campaigns, and knowledge was associated with some dietary behaviors. More research is needed to examine the impact of nutrition campaigns while also accounting for other psychosocial and environmental factors that may affect soda, fruit, and vegetable consumption.