Associations Between Patient Comfort with a Primary Care Provider and Three Measures of Behavioral Health Services Utilization.

BACKGROUND: Behavioral health services (BHS) can help improve and treat mental and emotional health problems. Yet, attitudinal and/or structural barriers often prevent individuals from accessing and benefiting from these services. Positive provider-patient interactions in healthcare, encompassing patient comfort with a primary care provider (PCP), which is often enhanced by shared decision-making, may mitigate the stigma associated with seeing a mental health professional; this may improve BHS utilization among patients who need these services. However, few studies have examined how patient comfort with a PCP, often through shared decision-making, may influence patients' BHS utilization in the real world. This study sought to address this gap in practice. METHOD: Multivariable regression analyses, using weighted data from an internet panel survey of Los Angeles County adults (n = 749), were carried out to examine the associations between patient comfort with a PCP and three measures of BHS utilization. Subsequent analyses were conducted to explore the extent to which shared decision-making moderated these associations. RESULTS: Participants who reported an intermediate or high comfort level with a provider had higher odds of reporting that they were likely to see (aOR = 2.10 and 3.84, respectively) and get advice (aOR = 2.75 and 4.76, respectively) from a mental health professional compared to participants who reported a low comfort level. Although shared decision-making influenced participants' likelihood of seeing and getting advice from a mental health professional, it was not a statistically significant moderator in these associations. CONCLUSION: Building stronger relationships with patients may improve BHS utilization, a provider practice that is likely underutilized.

Creating and Implementing a Community-Focused, Culturally Tailored Health Marketing Campaign to Address Menthol Cigarette Use in Los Angeles County.

Introduction: Menthol tobacco products have been marketed disproportionately to communities of color for decades. Methods: In Los Angeles County, California, a health marketing campaign, which used glossy visuals and attractive people in appealing poses, reminiscent of tobacco marketing tactics, was created and implemented to educate smokers on the health risks of using menthol cigarettes. The campaign encouraged smokers to make a quit attempt by offering access to free or low-cost resources through the Kick It California quitline and the LAQuits website (laquits.com). A survey tailored for public health professionals and community members from the approximately 382,000 people in the county who smoked menthol cigarettes and were exposed to their smoke (our primary audience) was administered to generate insights about this problem. Survey data were used to finesse the campaign creative materials prior to launch. Advertisement exposures, website visits, and quitline call volume were monitored and tabulated to assess the performance of the campaign. Results: At the conclusion of its initial run (February-April 2021), the "Done with Menthol" campaign had garnered more than 66 million impressions, received approximately 56,000 clicks on its various digital media platforms, and had click-through rates that surpassed industry benchmarks. The quitline call volume for African American and Latino subgroups were 1.9 and 1.8 times higher than the average inbound call volume for corresponding months during 2018 and 2019, respectively. In its second run (May-June 2023), the campaign garnered approximately 11 million additional impressions. Conclusions: Despite having a lower budget and fewer resources than the tobacco industry, the "Done with Menthol" campaign attained excellent reach and offered free, low-cost, and accessible resources to county residents interested in tobacco use cessation.

Community Engagement, Jurisdictional Experience, and Previous Tobacco-Related Ordinances in Neighboring Communities as Drivers of Flavored Tobacco Bans in Los Angeles County.

We examined whether a community engagement approach and jurisdictional attributes were associated with local action to restrict the sale of flavored tobacco products in Los Angeles County during 2019-2022. We estimated crude and adjusted risk ratios to examine these associations. Jurisdictions that used an active community engagement approach to adopt a flavored tobacco ban ordinance, those with previous experience adopting other tobacco-related ordinances, and those located next to communities that have an existing tobacco retail license ordinance were more likely than jurisdictions without these attributes to adopt a new ordinance to restrict the sale of flavored tobacco products. Efforts to adopt such an ordinance were generally more successful in jurisdictions where community members were engaged and policy makers were familiar with the adoption of public health ordinances.

Testing an Innovative Approach to Improve Hypertension Management at a Federally Qualified Health Center.

Despite the availability of effective treatments, hypertension control rates remain inadequate in the United States and locally in Los Angeles County. To address this health condition, QueensCare Health Centers developed and launched a team-based hypertension management program that was led by clinical pharmacists and designed to mitigate treatment barriers encountered at the system, provider, and patient levels. System- and provider-focused strategies included incorporating self-monitored blood pressure values into the electronic health record and retraining clinicians to regularly review these values; adding a community health worker to the disease management team; and utilizing clinical pharmacists to assess and titrate medications. Patient-focused strategies included tailoring education materials to reduce literacy and linguistic barriers; providing tailored one-on-one education and support; and providing blood pressure cuffs and pedometers. This multilevel intervention serves as a practical example of how team-based care can be optimized at a Federally Qualified Health Center.

Using Health Navigators to Connect At-Risk Clients to Community Resources.

CONTEXT: The coupling of health care services with complementary resources that address unmet social needs is a progressively popular approach for improving health outcomes among low-income populations. Community health workers are increasingly recognized as a helpful intermediary for clients navigating community and clinical services. PROGRAM: The Wellness Center at the Historic General Hospital in East Los Angeles employs a team of community health workers, referred to as Health Navigators, who are trained to link low-income clients to resources such as chronic disease management programs, food pantries, free or low-cost legal aid, health insurance enrollment, group fitness classes, and counseling and peer support services. IMPLEMENTATION: The Center's model of practice has evolved over time, continuously increasing the breadth and depth of services provided by the Health Navigator team. Its goal has been to address clients' unmet social needs while optimizing their health outcomes through the building of stronger community-clinical linkages. EVALUATION: A program review showed that Health Navigators serve as a critical bridge for clients navigating a complex network of health and social services. They actively engage, recruit, and deliver services to clients. Since 2014, the Health Navigator team has connected more than 28 000 unique clients to resources for health and well-being. DISCUSSION: By using Health Navigators to assist clients with community resource engagement, the Center has prototyped and promoted an approach that complements clinical care, strengthening the community-clinical linkages that are needed to meaningfully manage chronic disease outside of the hospital or clinic setting.

Developing an index of dose of exposure to early childhood obesity community interventions.

The recognition of the role of the environment in contributing to the obesity epidemic has led to increasing efforts to address obesity through environmental or place-based approaches in the past decade. This has challenged the use of the quasi-experimental design for evaluating community interventions. The objective of this study is to describe the development of an index of dose of exposure to community interventions that impact early childhood obesity. The goal is to provide an alternative means for evaluating the impact of multiple intervention strategies that target the same community at the same time. Two workgroups developed domains, constructs and protocols for estimating a "community intervention dose index" (CIDI). Information used to develop the protocol came from multiple sources including databases and reports of major funding organizations on obesity-related interventions implemented in Los Angeles County from 2005 to 2015, key informant interviews, and published literature. The workgroups identified five domains relevant to the consideration of dose of exposure to interventions: physical resources, social resources, context, capacity development, and programs and policies; developed a system for classifying programs and policies into macro- and micro-level intervention strategies; and sought ratings of strategy effectiveness from a panel of 13 experts using the Delphi technique, to develop an algorithm for calculating CIDI that considers intervention strength, reach and fidelity. This CIDI can be estimated for each community and used to evaluate the impact of multiple programs that use a myriad of intervention strategies for addressing a defined health outcome.

Implementing a Healthy Food Distribution Program: A Supply Chain Strategy to Increase Fruit and Vegetable Access in Underserved Areas.

Increasing access to fresh produce in small retail venues could improve the diet of people in underserved communities. However, small retailers face barriers to stocking fresh produce. In 2014, an innovative distribution program, Community Markets Purchasing Real and Affordable Foods (COMPRA), was launched in Los Angeles with the aim of making it more convenient and profitable for small retailers to stock fresh produce. Our case study describes the key processes and lessons learned in the first 2 years of implementing COMPRA. Considerable investments in staff capacity and infrastructure were needed to launch COMPRA. Early successes included significant week-to-week increases in the volume of produce distributed. Leveraging partnerships, maintaining a flexible operational and funding structure, and broadly addressing store owners' needs contributed to initial gains. We describe key challenges and next steps to scaling the program. Lessons learned from implementing COMPRA could inform other jurisdictions considering supply-side approaches to increase access to healthy food.

From Tobacco to Obesity Prevention Policies: A Framework for Implementing Community-Driven Policy Change.

Efforts to reverse the obesity epidemic require policy, systems, and environmental (PSE) change strategies. Despite the availability of evidence-based and other promising PSE interventions, limited evidence exists on the "how-to" of transitioning them into practice. For the past 13 years, the Los Angeles County Department of Public Health has been building capacity among community residents and other stakeholders to create effective community coalitions and to implement well-designed policy strategy campaigns using an evidence-based approach to policy change, the policy adoption model (PAM). Implementing a phase-based approach to policy change, the PAM was initially used to support the passage of over 140 tobacco control and prevention policies in Los Angeles County. Following these successes, Los Angeles County Department of Public Health applied the PAM to obesity prevention, operationalizing the policy process by training community residents and other stakeholders on the use of the model. The PAM has shown to be helpful in promoting PSE change in tobacco control and obesity prevention, suggesting a local-level model potentially applicable to other fields of public health seeking sustainable, community-driven policy change.

Evaluating the Potential Health and Revenue Outcomes of a 100% Healthy Vending Machine Nutrition Policy at a Large Agency in Los Angeles County, 2013-2015.

CONTEXT: Healthy vending machine policies are viewed as a promising strategy for combating the growing obesity epidemic in the United States. Few studies have evaluated the short- and intermediate-term outcomes of healthy vending policies, especially for interventions that require 100% healthy products to be stocked. OBJECTIVE: To evaluate the potential impact of a 100% healthy vending machine nutrition policy. DESIGN: The vendor's quarterly revenue, product sales records, and nutritional information data from 359 unique vending machines were used to conduct a baseline and follow-up policy analysis. SETTING: County of Los Angeles facilities, 2013-2015. PARTICIPANTS: Vending machines in facilities located across Los Angeles County. INTERVENTION: A healthy vending machine policy executed in 2013 that required 100% of all products sold in contracted machines meet specified nutrition standards. OUTCOME MEASURES: Policy adherence; average number of calories, sugar, and sodium in food products sold; revenue change. RESULTS: Policy adherence increased for snacks and beverages sold by the vending machines by 89% and 98%, respectively. Average snack and beverage revenues decreased by 37% and 34%, respectively, during the sampled period. CONCLUSIONS: Although a 100% healthy vending policy represents a promising strategy for encouraging purchases of healthier foods, steps should be taken to counteract potential revenue changes when planning its implementation.

Early Impacts of a Healthy Food Distribution Program on the Availability and Price of Fresh Fruits and Vegetables in Small Retail Venues in Los Angeles.

Healthy food distribution programs that allow small retailers to purchase fresh fruits and vegetables at wholesale prices may increase the profitability of selling produce. While promising, little is known about how these programs affect the availability of fresh fruits and vegetables in underserved communities. This study examined the impacts of a healthy food distribution program in Los Angeles County over its first year of operation (August 2015-2016). Assessment methods included: (1) a brief survey examining the characteristics, purchasing habits, and attitudes of stores entering the program; (2) longitudinal tracking of sales data examining changes in the volume and variety of fruits and vegetables distributed through the program; and (3) the collection of comparison price data from wholesale market databases and local grocery stores. Seventeen stores participated in the program over the study period. One-fourth of survey respondents reported no recent experience selling produce. Analysis of sales data showed that, on average, the total volume of produce distributed through the program increased by six pounds per week over the study period (95% confidence limit: 4.50, 7.50); trends varied by store and produce type. Produce prices offered through the program approximated those at wholesale markets, and were lower than prices at full-service grocers. Results suggest that healthy food distribution programs may reduce certain supply-side barriers to offering fresh produce in small retail venues. While promising, more work is needed to understand the impacts of such programs on in-store environments and consumer behaviors.

A Framework for Implementing the National Diabetes Prevention Program in Los Angeles County.

INTRODUCTION: Preventing type 2 diabetes is a public health priority in the United States. An estimated 86 million Americans aged 20 years or older have prediabetes, 90% of whom are unaware they have it. The National Diabetes Prevention Program (NDPP) has the potential to reduce the incidence of type 2 diabetes; however, little is known about the best way to institutionalize such a program in a jurisdiction with a racially/ethnically diverse population. The objective of this study was to develop a practice-grounded framework for implementing the NDPP in Los Angeles County. METHODS: In 2015, the Los Angeles County Department of Public Health (LACDPH) partnered with Ad Lucem Consulting to conduct a 3-stage formative assessment that consisted of 1) in-depth interviews with key informants representing community-based organizations to learn about their experiences implementing the NDPP and similar lifestyle-change programs and 2) 2 strategic planning sessions to obtain input and feedback from the Los Angeles County Diabetes Prevention Coalition. LACDPH identified core activities to increase identification of people with type 2 diabetes and referral and enrollment of eligible populations in the NDPP. RESULTS: We worked with LACDPH and key informants to develop a 3-pronged framework of core activities to implement NDPP: expanding outreach and education, improving health care referral systems and protocols, and increasing access to and insurance coverage for NDPP. The framework will use a diverse partner network to advance these strategies. CONCLUSION: The framework has the potential to identify people with prediabetes and to expand NDPP among priority populations in Los Angeles County and other large jurisdictions by using a diverse partner network.

Pharmacist-Driven Strategies for Hypertension Management in Los Angeles: A Community and Stakeholder Needs Assessment, 2014-2015.

In 2014, the Los Angeles County Department of Public Health received federal funding to improve the prevention and control of hypertension in the population through team-based health care delivery models, such as pharmacist-led medication therapy management. To inform this work, the department conducted a 3-part needs assessment consisting of 1) a targeted context scan of regional policies and efforts, 2) a key stakeholder survey, and 3) a public opinion internet-panel survey of Los Angeles residents. Results suggest that political will and professional readiness exists for expansion of pharmacist-led medication management strategies in Los Angeles. However, several infrastructure and economic barriers, such as a lack of sufficient payment or reimbursement mechanisms for these services, impede progress. The department is using assessment results to address barriers and shape efforts in scaling up pharmacist-led programming in Los Angeles.

Access to and Use of Schools for Physical Activity Among Adults in Los Angeles County.

Formal agreements that outline conditions for community use of school facilities represent a potentially attractive approach to increasing access to places for physical activity in underresourced areas. Despite growing interest in these shared use agreements, limited data are available on their population-level impacts. This study used data collected via an Internet panel survey in spring 2014 (n = 1,006) to examine the extent of public awareness and use of school-based physical activity resources in Los Angeles County. Weighted data were analyzed using logistic regression to examine associations among access to and use of schools, demographics, and behavioral and environmental factors. Negative binomial regression was performed to test the association between access to school-based physical activity resources and physical activity. Results suggest that a large percentage (57.7%) of people have access to school-based physical activity resources; however, only a portion (30.3%) use them. Safety of school grounds and whether onsite programming was offered were positively associated with use. In light of these findings, additional efforts may be needed to help optimize community use of schools for physical activity. These results can help inform program planning and implementation in communities considering shared use policies.

What menu changes do restaurants make after joining a voluntary restaurant recognition program?

Programs that recognize restaurants for offering healthful options have emerged as a popular strategy to address the obesity epidemic; however, program fidelity and business responses to such programs are rarely assessed. This study sought to examine how retail restaurants in Los Angeles County chose to comply with participation criteria required by the Choose Health LA Restaurants initiative in the region; the program recognizes restaurants for offering reduced-size portions and healthy children's meals. Menus of all restaurants that joined within 1 year of program launch (n = 17 restaurant brands) were assessed for changes. Nine of the 17 brands made changes to their menus to meet participation criteria for reduced-size portions while 8 of the 10 restaurant brands that offered children's menus made changes to improve the healthfulness of children's meals. Results of this comparative assessment lend support to restaurant compliance with program criteria and menu improvements, even though they are voluntary, representing an important step toward implementing this strategy in the retail environment.

Using population reach as a proxy metric for intervention impact to prioritize selection of obesity prevention strategies in Los Angeles County, 2010-2012.

Recent federal initiatives have used estimates of population reach as a proxy metric for intervention impact, in part to inform resource allocation and programmatic decisions about competing priorities in the community. However, in spite of its utility, population reach as a singular metric of intervention impact may be insufficient for guiding multifaceted program decisions. A more comprehensive, validated approach to measure or forecast dose may complement reach estimates to inform decision makers about optimal ways to use limited resources.

Restaurant owners' perspectives on a voluntary program to recognize restaurants for offering reduced-size portions, Los Angeles County, 2012.

INTRODUCTION: Reducing the portion size of food and beverages served at restaurants has emerged as a strategy for addressing the obesity epidemic; however, barriers and facilitators to achieving this goal are not well characterized. METHODS: In fall 2012, the Los Angeles County Department of Public Health conducted semistructured interviews with restaurant owners to better understand contextual factors that may impede or facilitate participation in a voluntary program to recognize restaurants for offering reduced-size portions. RESULTS: Interviews were completed with 18 restaurant owners (representing nearly 350 restaurants). Analyses of qualitative data revealed 6 themes related to portion size: 1) perceived customer demand is central to menu planning; 2) multiple portion sizes are already being offered for at least some food items; 3) numerous logistical barriers exist for offering reduced-size portions; 4) restaurant owners have concerns about potential revenue losses from offering reduced-size portions; 5) healthful eating is the responsibility of the customer; and 6) a few owners want to be socially responsible industry leaders. CONCLUSION: A program to recognize restaurants for offering reduced-size portions may be a feasible approach in Los Angeles County. These findings may have applications for jurisdictions interested in engaging restaurants as partners in reducing the obesity epidemic.

Food Insecurity Screening in Safety-Net Clinics in Los Angeles County: Lessons for Post-Pandemic Planning.

INTRODUCTION: Food insecurity is a major public health problem in the United States which was exacerbated by the COVID-19 pandemic. We used a multi-method approach to understand barriers and facilitators to implementing food insecurity screening and referrals at safety net health care clinics in Los Angeles County before the pandemic. METHODS: In 2018, we surveyed 1013 adult patients across eleven safety-net clinic waiting rooms in Los Angeles County. Descriptive statistics were generated to characterize food insecurity status, attitudes toward receiving food assistance, and use of public assistance programs. Twelve interviews with clinic staff explored effective and sustainable approaches to food insecurity screening and referral. RESULTS: Patients welcomed the opportunity to access food assistance in the clinic setting; 45% preferred discussing food issues directly with the doctor. Missed opportunities to screen for food insecurity and refer patients to food assistance were identified at the clinic level. Barriers to these opportunities included: competing demands on staff and clinic resources, difficulty establishing referral pathways, and doubts surrounding data. DISCUSSION: Integrating food insecurity assessment in clinical settings requires infrastructure support, staff training, clinic buy-in, and more coordination and oversight from local government, health center entities, and public health agencies.

Building bi-directional referral and communication pathways across the community-clinic divide: Experiences from a systems-informed innovation project in Los Angeles.

Bi-directional communication and referral pathways (BCRPs) between clinics and community-based organizations could promote well-being among vulnerable populations with complex and overlapping health and social needs. While BCRPs are promising, establishing them is complex, involving system and process changes across diverse organizational settings. To date, few models have been implemented or empirically tested. This article describes an innovation and planning project to build a BCRP, linking patients in safety net primary care clinics to a comprehensive suite of community-based health and wellness supports in Los Angeles. During a year-long process, a multi-sector team iteratively engaged data to facilitate learning and improvement. The project proceeded through three distinct, but overlapping, phases: (1) Discovery, (2) Systems Mapping, and (3) BCRP Re-design and Testing, which were coordinated through frequent collaborative meetings. By using a stepwise systems-informed approach to collect and examine data, the team was able to generate new change ideas, dispel assumptions, and make transparent and informed decisions. It was critical to have engagement from both internal partners with knowledge of "on-the-ground" practice realities, and external stakeholders with the fresh perspective needed to identify opportunities and define an improvement agenda. These efforts represent first steps towards implementing sustainable BCRPs and realizing their full potential to dynamically bridge the community-clinic divide and improve population health. Other jurisdictions can learn from and adapt the practical data-driven approach used in Los Angeles to build BCRPs that will be thoroughly operationalized, consistently implemented, and optimized within their own unique contexts.