Partnering With Community Health Workers to Address COVID-19 Health Inequities: Experiences of the California Alliance Against COVID-19.

With funding from the National Institutes of Health's Community Engagement Alliance, starting in fall 2020, 11 academic medical centers and 75 community partners came together as the California Alliance Against COVID-19 to address COVID-19 inequities in California. Using data from focus groups, statewide meetings, and a statewide partner survey, we describe how promotoras and community health workers (P/CHWs; n = 540) helped to promote access to COVID-19 information, testing, and vaccination. We highlight opportunities to promote health equity among other public health collaborators with a P/CHW model. (Am J Public Health. 2024;114(S1):S45-S49. https://doi.org/10.2105/AJPH.2023.307471).

Addressing racial/ethnic inequities in vaccine hesitancy and uptake: lessons learned from the California alliance against COVID-19.

Lack of trust in biomedical research, government, and health care systems, especially among racial/ethnic minorities and under-resourced communities, is a longstanding issue rooted in social injustice. The COVID-19 pandemic has further highlighted existing health and socioeconomic inequities and increased the urgency for solutions to provide access to timely, culturally, and linguistically appropriate evidence-based information about COVID-19; and ultimately to promote vaccine uptake. California's statewide alliance STOP COVID-19 CA (comprising eleven sites), leverages long standing community partnerships to better understand concerns, misinformation, and address racial/ethnic inequities in vaccine hesitancy and uptake. Using data from the California CEAL Communication Working Group, we demonstrate the wide range of strategies, communication methods, languages, and trusted messengers that have been effective in reaching diverse communities across the state. We also showcase challenges and lessons learned, such as the importance of including trusted community partners to share information or provide vaccines. These approaches, rooted in community engagement, are crucial for addressing inequities and responding to future public health emergencies.

Unified in Our Diversity to Address Health Disparities Among Asian Americans, Native Hawaiians, and Pacific Islanders.

The COVID-19 pandemic disproportionately impacted Asian Americans, Native Hawaiians, and Pacific Islanders (AA/NHPIs) in the United States. AA/NHPIs have historically been subjected to discrimination, which was exacerbated by the pandemic. To bring attention to their unique concerns, an AA/NHPI Interest Group of the National Institutes of Health Community Engagement Alliance Against COVID-19 Disparities (CEAL) was formed. This article highlights major concerns raised by the Interest Group: The pervasive and arbitrary practice of data aggregation by public health agencies and health-related researchers, the lack of culturally responsive services in the context of cultural safety, and leadership underrepresentation.

STOP COVID-19 CA: Community engagement to address the disparate impacts of the COVID-19 pandemic in California.

Objective: To describe the early activities and lessons of the Share, Trust, Organize, Partner COVID-19 California Alliance (STOP COVID-19 CA), the California awardee of the NIH-funded multi-state Community Engagement Alliance (CEAL) against COVID-19. The Alliance was established to ensure equity in Coronavirus-19 disease (COVID-19) research, clinical practice, and public health for communities most impacted by the COVID-19 pandemic. Study setting: The STOP COVID-19 CA Alliance network of 11 universities and affiliated partner community-based organizations (CBOs) across California. Study design: Mixed methods evaluation consisting of an analysis of activity (August 2020 to December 2021) detailed in reports submitted by community-academic teams and a survey (August 2021) of academic investigators and affiliated community-based organization (CBO) partners. Data collection: We summarized activities from the 11 community-academic teams' progress reports and described results from an online survey of academic investigators and CBO partners in the California Alliance. Principal findings: A review of progress reports (n = 256) showed that teams fielded surveys to 11,000 Californians, conducted 133 focus groups, partnered with 29 vaccine/therapeutics clinical trials, and led more than 300 town halls and vaccine events that reached Californians from communities disproportionately impacted by COVID-19. Survey responses from academic investigators and CBO partners emphasized the importance of learning from the successes and challenges of the California Alliance teams' COVID-19 initiatives. Both academic and CBO respondents highlighted the need for streamlined federal and institutional administrative policies, and fiscal practices to promote more effective and timely operations of teams in their efforts to address the numerous underlying health and social disparities that predispose their communities to higher rates of, and poor outcomes from, COVID-19. Conclusions: STOP COVID-19 CA represents a new and potentially sustainable statewide community engagement model for addressing health disparities in multiethnic/multicultural and geographically dispersed communities.

Health disparities and equity in the era of COVID-19.

Over the last year, COVID-19 has emerged as a highly transmissible and lethal infection. As we address this global pandemic, its disproportionate impact on Black, Indigenous, and Latinx communities has served to further magnify the health inequities in access and treatment that persist in our communities. These sobering realities should serve as the impetus for reexamination of the root causes of inequities in our health system. An increased commitment to strategic partnerships between academic and nonacademic health systems, industry, local communities, and policy-makers may serve as the foundation. Here, we examine the impact of the recent COVID-19 pandemic on health care inequities and propose a strategic roadmap for integration of clinical and translational research into our understanding of health inequities.

Advancing health equity through CTSA programs: Opportunities for interaction between health equity, dissemination and implementation, and translational science.

Dissemination and implementation (D&I) science is dedicated to studying how to effectively translate and apply research in real-world contexts. There has been increasing interest in health equity within the D&I field to ensure the equitable implementation of evidence-based programs/practices across a range of diverse populations and settings. At the same time, health equity researchers recognize the potential of D&I science to promote the more widespread dissemination, implementation, and sustainment of evidence-based interventions to address health inequities. The National Center for Accelerating Clinical and Translational Science Clinical and Translational Science Award (CTSA) Program has been a champion for community engagement and translational scholarship in its mission to improve individual and population health. The overall CTSA infrastructure and resources within and among CTSA hubs are well-equipped to facilitate a health equity focus to D&I across the phases of translational research. This paper proposes a framework that demonstrates the interaction and opportunities between health equity and D&I science and highlights how CTSAs can support and facilitate wider efforts in translational research with a focus on equitable D&I.

Diversity and inclusion for the All of Us research program: A scoping review.

The All of Us Research Program (All of Us) is a national effort to accelerate health research by exploring the relationship between lifestyle, environment, and genetics. It is set to become one of the largest research efforts in U.S. history, aiming to build a national resource of data from at least one million participants. All of Us aims to address the need for more diversity in research and set the stage for that diversity to be leveraged in precision medicine research to come. This paper describes how the program assessed demographic characteristics of participants who have enrolled in other U.S. biomedical research cohorts to better understand which groups are traditionally represented or underrepresented in biomedical research. We 1) reviewed the enrollment characteristics of national cohort studies like All of Us, and 2) surveyed the literature, focusing on key diversity categories essential to the program's enrollment aims. Based on these efforts, All of Us emphasizes enrollment of racial and ethnic minorities, and has formally designated the following additional groups as historically underrepresented: individuals-with inadequate access to medical care; under the age of 18 or over 65; with an annual household income at or below 200% of the federal poverty level; who have a cognitive or physical disability; have less than a high school education or equivalent; are intersex; identify as a sexual or gender minority; or live in rural or non-metropolitan areas. Research accounting for wider demographic variability is critical. Only by ensuring diversity and by addressing the very barriers that limit it, can we position All of Us to better understand and tackle health disparities.

The Diabetes Prevention Program for Underserved Populations: A Brief Review of Strategies in the Real World.

IN BRIEF This review highlights examples of the translation of the Diabetes Prevention Program (DPP) to underserved populations. Here, underserved populations are defined as groups whose members are at greater risk for health conditions such as diabetes but often face barriers accessing treatment. Strategies to develop and evaluate future DPP translations are discussed.

Development of the Initial Surveys for the All of Us Research Program.

BACKGROUND: The All of Us Research Program is building a national longitudinal cohort and collecting data from multiple information sources (e.g., biospecimens, electronic health records, and mobile/wearable technologies) to advance precision medicine. Participant-provided information, collected via surveys, will complement and augment these information sources. We report the process used to develop and refine the initial three surveys for this program. METHODS: The All of Us survey development process included: (1) prioritization of domains for scientific needs, (2) examination of existing validated instruments, (3) content creation, (4) evaluation and refinement via cognitive interviews and online testing, (5) content review by key stakeholders, and (6) launch in the All of Us electronic participant portal. All content was translated into Spanish. RESULTS: We conducted cognitive interviews in English and Spanish with 169 participants, and 573 individuals completed online testing. Feedback led to over 40 item content changes. Lessons learned included: (1) validated survey instruments performed well in diverse populations reflective of All of Us; (2) parallel evaluation of multiple languages can ensure optimal survey deployment; (3) recruitment challenges in diverse populations required multiple strategies; and (4) key stakeholders improved integration of surveys into larger Program context. CONCLUSIONS: This efficient, iterative process led to successful testing, refinement, and launch of three All of Us surveys. Reuse of All of Us surveys, available at http://researchallofus.org, may facilitate large consortia targeting diverse populations in English and Spanish to capture participant-provided information to supplement other data, such as genetic, physical measurements, or data from electronic health records.

Results From a Trial of an Online Diabetes Prevention Program Intervention.

INTRODUCTION: Online Diabetes Prevention Programs (DPPs) can be scaled up and delivered broadly. However, little is known about real-world effectiveness and how outcomes compare with in-person DPP. This study examined online DPP weight loss and participation outcomes and secondarily compared outcomes among participating individuals with parallel in-person interventions. STUDY DESIGN: A large non-randomized trial supplemented by a comparative analysis of participating individuals from a concurrent trial of two parallel in-person programs: in-person DPP and the Veterans Administration's standard of care weight loss program (MOVE!). SETTING/PARTICIPANTS: Obese/overweight Veterans with prediabetes enrolled in online DPP (n = 268) between 2013 and 2014. Similar eligibility criteria were used to enroll in-person participants between 2012 and 2014 (n = 273 in-person DPP, n = 114 MOVE!) within a separate trial. INTERVENTION: Online DPP included a virtual group format, live e-coach, weekly modules delivered asynchronously, and wireless home scales. In-person programs included eight to 22 group-based, face-to-face sessions. MAIN OUTCOMES MEASURES: Weight change at 6 and 12 months using wirelessly uploaded home scale data or electronic medical record weights from clinical in-person visits. Outcomes were analyzed between 2015 and 2017. RESULTS: From 1,182 invitations, 268 (23%) participants enrolled in online DPP. Among these, 158 (56%) completed eight or more modules; mean weight change was -4.7kg at 6 months and -4.0kg at 12 months. In a supplemental analysis of participants completing one or more sessions/modules, online DPP participants were most likely to complete eight or more sessions/modules (87% online DPP vs 59% in-person DPP vs 55% MOVE!, p < 0.001). Online and in-person DPP participants lost significantly more weight than MOVE! participants at 6 and 12 months; there was no significant difference in weight change between online and in-person DPP. CONCLUSIONS: An intensive, multifaceted online DPP intervention had higher participation but similar weight loss compared to in-person DPP. An intensive, multifaceted online DPP intervention may be as effective as in-person DPP and help expand reach to those at risk.

Implementation findings from a hybrid III implementation-effectiveness trial of the Diabetes Prevention Program (DPP) in the Veterans Health Administration (VHA).

BACKGROUND: The Diabetes Prevention Program (DPP) is an effective lifestyle intervention to reduce incidence of type 2 diabetes. However, there are gaps in knowledge about how to implement DPP. The aim of this study was to evaluate implementation of DPP via assessment of a clinical demonstration in the Veterans Health Administration (VHA). METHODS: A 12-month pragmatic clinical trial compared weight outcomes between the Veterans Affairs Diabetes Prevention Program (VA-DPP) and the usual care MOVE!® weight management program (MOVE!). Eligible participants had a body mass index (BMI) ≥30 kg/m2 (or BMI ≥ 25 kg/m2 with one obesity-related condition), prediabetes (glycosylated hemoglobin (HbA1c) 5.7-6.5% or fasting plasma glucose (FPG) 100-125 mg/dL), lived within 60 min of their VA site, and had not participated in a weight management program within the last year. Established evaluation and implementation frameworks were used to guide the implementation evaluation. Implementation barriers and facilitators, delivery fidelity, participant satisfaction, and implementation costs were assessed. Using micro-costing methods, costs for assessment of eligibility and scheduling and maintaining adherence per participant, as well as cost of delivery per session, were also assessed. RESULTS: Several barriers and facilitators to Reach, Adoption, Implementation, Effectiveness and Maintenance were identified; barriers related to Reach were the largest challenge encountered by site teams. Fidelity was higher for VA-DPP delivery compared to MOVE! for five of seven domains assessed. Participant satisfaction was high in both programs, but higher in VA-DPP for most items. Based on micro-costing methods, cost of assessment for eligibility was $68/individual assessed, cost of scheduling and maintaining adherence was $328/participant, and cost of delivery was $101/session. CONCLUSIONS: Multi-faceted strategies are needed to reach targeted participants and successfully implement DPP. Costs for assessing patients for eligibility need to be carefully considered while still maximizing reach to the targeted population.

Practical partnered research to improve weight loss among overweight/obese veterans: lessons from the trenches.

BACKGROUND: Obesity and obesity-related conditions, such as type 2 diabetes, are a major issue for Veteran health. Veterans Health Administration (VA) researchers and health systems leaders have worked separately and together to provide more effective weight management programs for Veterans. Although randomized clinical trials are often considered the gold standard for establishing efficacy of interventions in controlled circumstances, pragmatic clinical trials (PCTs) provide agility for translation. MAIN TEXT: VA researchers and health system leaders collaboratively designed a PCT to compare the Diabetes Prevention Program (VA-DPP) to usual care (MOVE!®) in promoting weight loss and glycemic control among overweight/obese Veterans with prediabetes. Together, they navigated the tensions that exist between quality improvement and research activities, facing challenges but reaping significant rewards. Early findings led to updated national guidance for delivering obesity treatment in VA. SHORT CONCLUSION: Partnered research and the use of PCTs can be powerful strategies for accelerating evidence-based findings into practice. Collaborative partnerships between researchers and health systems leaders can help enhance and sustain translation in real-world settings.

Diabetes Prevention Program Translation in the Veterans Health Administration.

INTRODUCTION: This clinical demonstration trial compared the effectiveness of the Veterans Affairs Diabetes Prevention Program (VA-DPP) with an evidence-based usual care weight management program (MOVE!®) in the Veterans Health Administration health system. DESIGN: Prospective, pragmatic, non-randomized comparative effectiveness study of two behavioral weight management interventions. SETTING/PARTICIPANTS: Obese/overweight Veterans with prediabetes were recruited from three geographically diverse VA sites between 2012 and 2014. INTERVENTION: VA-DPP included 22 group-based intensive lifestyle change sessions. MAIN OUTCOME MEASURES: Weight change at 6 and 12 months, hemoglobin A1c (HbA1c) at 12 months, and VA health expenditure changes at 15 months were assessed using VA electronic health record and claims data. Between- and within-group comparisons for weight and HbA1c were done using linear mixed-effects models controlling for age, gender, race/ethnicity, baseline outcome values, and site. Analyses were conducted in 2015-2016. RESULTS: A total of 387 participants enrolled (273 VA-DPP, 114 MOVE!). More VA-DPP participants completed at least one (73.3% VA-DPP vs 57.5% MOVE! p=0.002); four (57.5% VA-DPP vs 42.5% MOVE!, p=0.007); and eight or more sessions (42.5% VA-DPP vs 31% MOVE!, p=0.035). Weight loss from baseline was significant at both 6 (p<0.001) and 12 months (p<0.001) for VA-DPP participants, but only significant at 6 months for MOVE! participants (p=0.004). Between groups, there were significant differences in 6-month weight loss (-4.1 kg VA-DPP vs -1.9 kg MOVE!, p<0.001), but not 12-month weight loss (-3.4 kg VA-DPP vs -2.0 kg MOVE!, p=0.16). There were no significant differences in HbA1c change or outpatient, inpatient, and total VA expenditures. CONCLUSIONS: VA-DPP participants had higher participation rates and weight loss at 6 months, but similar weight, HbA1c, and health expenditures at 12 months compared to MOVE! PARTICIPANTS: Features of VA-DPP may help enhance the capability of MOVE! to reach a larger proportion of the served population and promote individual-level weight maintenance.

Comparative Effectiveness of Wellness Programs: Impact of Incentives on Healthcare Costs for Obese Enrollees.

INTRODUCTION: Employee wellness programs show mixed effectiveness results. This study examined the impact of an insurer's lifestyle modification program on healthcare costs of obese individuals. METHODS: This nonrandomized comparative effectiveness study evaluated changes in healthcare costs for participants in two incentivized programs, an Internet-mediated pedometer-based walking program (WalkingSpree, n=7,594) and an in-person weight-loss program (Weight Watchers, n=5,764). The primary outcome was the change in total healthcare costs from the baseline year to the year after program participation. Data were collected from 2009 to 2011 and the analysis was done in 2014-2015. RESULTS: After 1 year, unadjusted mean costs decreased in both programs, with larger decreases for Weight Watchers participants than WalkingSpree participants (-$1,055.39 vs -$577.10, p=0.019). This difference was driven by higher rates of women in Weight Watchers, higher baseline total costs among women, and a greater decrease in costs for women in Weight Watchers (-$1,037.60 vs -$388.50, p=0.014). After adjustment for baseline costs, there were no differences by program or gender. CONCLUSIONS: Comparable cost reductions in both programs suggest that employers may want to offer more than one choice of incentivized wellness program with monitoring to meet the diverse needs of employees.

Integrating Physical Activity in Primary Care Practice.

Based on a collaborative symposium in 2014 hosted by the Society of Behavioral Medicine (SBM) and the American College of Sports Medicine (ACSM), this paper presents a model for physical activity counseling for primary care physicians (PCPs). Most US adults do not meet national recommendations for physical activity levels. Socioecological factors drive differences in physical activity levels by geography, sex, age, and racial/ethnic group. The recent Patient Protection and Affordable Care Act incentivizes PCPs to offer patients physical activity counseling. However, PCPs have reported socioecological barriers to physical activity counseling and also patient barriers to physical activity, spanning from the individual to the environmental (eg, lack of safe spaces for physical activity), policy (eg, reimbursement policies), and organizational (eg, electronic medical record protocols, worksite norms/policies) levels. The aims of this paper are to: 1) discuss barriers to PCP counseling for physical activity; 2) provide evidence-based strategies and techniques to help PCPs address these counseling barriers; and 3) suggest practical steps for PCPs to counsel patients on physical activity using strategies and supports from policy, the primary care team, and other support networks.

Patient Activation is Inconsistently Associated with Positive Health Behaviors Among Obese Safety Net Patients.

We examine the association of patient activation and physical activity and fruit and vegetable consumption among obese safety net patients. Adult obese patients (n = 198) of three safety net clinics completed a survey assessing patient activation, physical activity, fruit and vegetable consumption, care experiences, and health status. Multivariate logistic regression models incrementally assessed the adjusted relation of patient activation and physical activity and fruit and vegetable consumption. In adjusted analyses, higher activated patients had higher odds [Odds ratio (OR) 1.58, p < 0.01] of consuming fruits and vegetables daily than less activated patients. There was no significant association between patient activation and regular physical activity. Engaging in regular physical activity appears to be difficult, even for highly activated patients. In contrast, additional fruit and vegetable consumption is a relatively easier change. Patient activation was inconsistently associated with two positive health behaviors among obese safety net patients.

Frontline experiences of a practice redesign to improve self-management of obesity in safety net clinics.

Teamlets of physicians and medical assistants may help improve obesity management in primary care settings. We aimed to understand the barriers and facilitators of implementing a teamlet approach to managing obesity in 3 safety net clinics. Key stakeholder interviews (n = 21) were conducted both during early implementation of practice change and 6 months later. Patient surveys (n = 393) examined obese patient activation and health status. Insufficient program resources and limited patient engagement due to external factors were implementation barriers despite fairly high patient activation. Staff members need time and resources to execute new responsibilities to support obesity management in safety net settings. Because of high turnover, multiple supporters may improve sustainability.

A midpoint process evaluation of the Los Angeles Basin Racial and Ethnic Approaches to Community Health Across the US (REACH US) Disparities Center, 2007-2009.

BACKGROUND: Racial/ethnic minority groups have higher risks for disease resulting from obesity. COMMUNITY CONTEXT: The University of California, Los Angeles, and the Los Angeles County Department of Public Health partnered with community organizations to disseminate culturally targeted physical activity and nutrition-based interventions in worksites. METHODS: We conducted community dialogues with people from 59 government and nonprofit health and social service agencies to develop wellness strategies for implementation in worksites. Strategies included structured group exercise breaks and serving healthy refreshments at organizational functions. During the first 2 years, we subcontracted with 6 community-based organizations (primary partners) who disseminated these wellness strategies to 29 organizations within their own professional networks (secondary worksites) through peer modeling and social support. We analyzed data from the first 2 years of the project to evaluate our dissemination approach. OUTCOME: Primary partners had difficulty recruiting organizations in their professional network as secondary partners to adopt wellness strategies. Within their own organizations, primary partners reported significant increases in implementation in 2 of the 6 core organizational strategies for promoting physical activity and healthy eating. Twelve secondary worksites that completed organizational assessments on 2 occasions reported significant increases in implementation in 4 of the 6 core organizational strategies. INTERPRETATION: Dissemination of organizational wellness strategies by trained community organizations through their existing networks (train-the-trainer) was only marginally successful. Therefore, we discontinued this dissemination approach and focused on recruiting leaders of organizational networks.

Integration of short bouts of physical activity into organizational routine a systematic review of the literature.

CONTEXT: Recommended daily physical activity accumulated in short intervals (e.g., <10 minutes) may be more feasible and appealing to the relatively sedentary populace than longer bouts. The purpose of this paper is to present a systematic review of the evidence for the effectiveness of short activity bouts incorporated into organizational routine as part of the regular "conduct of business." EVIDENCE ACQUISITION: PubMed, MEDLINE, and Google Scholar databases were searched in August 2009 (updated search in February and July 2010) to identify relevant, peer-reviewed journal articles and abstracts on school-, worksite-, and faith-based interventions of short, structurally integrated physical activity breaks. EVIDENCE SYNTHESIS: The majority of interventions implemented daily physical activity bouts of 10-15 minutes in length. Schools were the most common settings among the 40 published articles included in this review. The rigor of the studies varied by setting, with more than 75% of worksite versus 25% of school studies utilizing RCT designs. Studies focused on a broad range of outcomes, including academic/work performance indicators, mental health outcomes, and clinical disease risk indicators, in addition to physical activity level. Physical activity was the most commonly assessed outcome in school-based studies, with more than half of studies assessing and observing improvements in physical activity outcomes following the intervention. About a quarter of worksite-based studies assessed physical activity, and the majority found a positive effect of the intervention on physical activity levels. About half of studies also observed improvements in other relevant outcomes such as academic and work performance indicators (e.g., academic achievement, cognitive performance, work productivity); psychosocial factors (e.g., stress, mood); and clinical disease risk indicators (e.g., blood pressure, BMI). The average study duration was more than 1 year, and several reported outcomes at 3-6 years. CONCLUSIONS: Interventions integrating physical activity into organizational routine during everyday life have demonstrated modest but consistent benefits, particularly for physical activity, and these are promising avenues of investigation. The proportionately longer-term outcomes available in these studies compared with individual-level studies suggest that physical activity promotion strategies at the organizational level may be more sustainable.