Mapping Cumulative Risk in Delaware: Approach and Implications for Health Equity.

BACKGROUND: Addressing health equity requires attention to upstream determinants of health, including environmental and social factors that act in tandem to increase communities' exposure to and vulnerability to toxicants. Cumulative risk assessment, which evaluates combined risks from environmental and social factors, is a useful approach for estimating potential drivers of health disparities. We developed a cumulative risk score of multiple indices of environmental and social conditions and assessed block group-level differences in New Castle County, Delaware. METHODS: This cross-sectional study used choropleth maps to visualize the distribution of environmental, social, and cumulative risks and Moran's I statistics to assess spatial clustering of cumulative risk across the county and among individual block groups. RESULTS: Findings indicate that environmental risk rarely occurs without social risk and that environmental and social risks co-occur in distinct areas, resulting in large-scale clustering of cumulative risk. Areas of higher cumulative risk had more Black residents and people of lower socioeconomic status. CONCLUSIONS: Replicable measures of cumulative risk can show how environmental and social risks are inequitably distributed by race and socioeconomic status, as seen here in New Castle County. Such measures can support upstream approaches to reduce health disparities resulting from histories of environmental racism.

Geographic and social economic disparities in the risk of exposure to ambient air respiratory toxicants at Oklahoma licensed early care and education facilities.

BACKGROUND: Early life exposures to hazardous air pollutants has been associated with adverse asthma-related outcomes. Neighborhood-level social and economic factors play an essential role in the distribution of hazardous air pollutants and children spend a substantial amount of time at early care and education (ECE) facilities. While the indoor air quality of these facilities has been described, particularly for criteria air pollutants such as volatile organic compounds and particulate matter, little is known about the ambient air quality of ECE facilities. OBJECTIVES: We conducted a cross-sectional study to estimate the ambient air quality of Oklahoma licensed ECE facilities and to explore associations between ambient air quality and select geographic predictors. METHODS: We estimated ambient air quality using the total respiratory hazard quotient from the National Air Toxics Assessment according to the geographical location of licensed Oklahoma ECE facilities (N = 3184). We then determined whether urban and rural ECE facilities' air respiratory toxicant exposure risk differed by ECE facilities' neighborhood-level social and economic inequities including: 1) racial-ethnic minority community, 2) neighborhood socioeconomic status, and 3) residential segregation. RESULTS: Urban ECE facilities in Hispanic segregated counties were five times more likely to be at risk of high air respiratory exposure, adjusted for integrated urban counties (p < 0.0001, 95% CI [3.824, 7.699]). Rural ECE facilities in African American segregated counties were nine times more likely to be at risk of high air respiratory toxicant exposure, adjusted for integrated rural counties (p < 0.0001, 95% CI [5.641, 15.928]). CONCLUSION: We found geographically and socially disparate patterns of higher exposures to ambient air respiratory toxicants at Oklahoma ECE facilities. Safer siting policies and interventions are needed to mitigate air respiratory toxicant exposures, which may help to reduce asthma control disparities and improve respiratory health outcomes in Oklahoma ECE facilities.

Family child care home providers' self-reported nutrition and physical activity practices, self-efficacy, barriers and knowledge: baseline findings from happy healthy homes.

OBJECTIVE: Describe nutrition and physical activity practices, nutrition self-efficacy and barriers and food programme knowledge within Family Child Care Homes (FCCH) and differences by staffing. DESIGN: Baseline, cross-sectional analyses of the Happy Healthy Homes randomised trial (NCT03560050). SETTING: FCCH in Oklahoma, USA. PARTICIPANTS: FCCH providers (n 49, 100 % women, 30·6 % Non-Hispanic Black, 2·0 % Hispanic, 4·1 % American Indian/Alaska Native, 51·0 % Non-Hispanic white, 44·2 ± 14·2 years of age. 53·1 % had additional staff) self-reported nutrition and physical activity practices and policies, nutrition self-efficacy and barriers and food programme knowledge. Differences between providers with and without additional staff were adjusted for multiple comparisons (P < 0·01). RESULTS: The prevalence of meeting all nutrition and physical activity best practices ranged from 0·0-43·8 % to 4·1-16·7 %, respectively. Average nutrition and physical activity scores were 3·2 ± 0·3 and 3·0 ± 0·5 (max 4·0), respectively. Sum nutrition and physical activity scores were 137·5 ± 12·6 (max 172·0) and 48·4 ± 7·5 (max 64·0), respectively. Providers reported high nutrition self-efficacy and few barriers. The majority of providers (73·9-84·7 %) felt that they could meet food programme best practices; however, knowledge of food programme best practices was lower than anticipated (median 63-67 % accuracy). More providers with additional staff had higher self-efficacy in family-style meal service than did those who did not (P = 0·006). CONCLUSIONS: Providers had high self-efficacy in meeting nutrition best practices and reported few barriers. While providers were successfully meeting some individual best practices, few met all. Few differences were observed between FCCH providers with and without additional staff. FCCH providers need additional nutrition training on implementation of best practices.

Community Health Improvement Plans: An Analysis of Approaches Used by Local Health Departments.

CONTEXT: The Public Health Accreditation Board requires accredited local health departments (LHDs) to complete community health improvement plans (CHIPs). Evidence suggests that participatory planning frameworks, cross-sector collaboration, social determinants of health (SDOHs), and steering organizations are integral to effective public health planning. However, little is known about the degree to which LHDs incorporate these aspects during the CHIP process. OBJECTIVES: To describe the use of planning methods, SDOHs, cross-sector partnerships, and steering organizations during the CHIP development process among nationally accredited LHDs and to identify whether LHD jurisdictional size or region is associated with differences in use. DESIGN: The most recent CHIPs from 93% of all nationally accredited LHDs (n = 195) were qualitatively reviewed and numerically coded for each of the planning components to calculate frequency and degree of use. Differences in use of each component by LHDs' jurisdictional size and region were tested using the chi-square test. MAIN OUTCOME MEASURE: Use of CHIP planning frameworks, SDOH inclusion, cross-sector partnerships, and steering organizations. RESULTS: One-half of LHDs (53%) reported use of Mobilizing for Action through Planning and Partnerships, but nearly one-fourth of LHDs did not use any planning framework. LHDs with a large jurisdictional size (>500 000) were significantly more likely to include SDOHs to a high degree than LHDs with mid- (100 000-499 999) to small- (<99 999) jurisdictional size (P < .01). Similarly, large LHDs were more likely to include cross-sector partners except for the category community members, which were rarely (10%) included. Mid-sized LHDs were more likely to lead the CHIP steering committee (61%) than small (29%) and large (9%) LHDs (P < .01). Differences in use of the 4 components by region were less significant. CONCLUSIONS: Jurisdictional size, rather than region, was more strongly associated with LHD approaches to CHIP development. More studies are needed to determine how differences influence CHIP implementation and impact.

Legal Needs, Health, and Health Care Utilization Among Patients Participating in the Delaware Medical Legal Partnership.

CONTEXT: Unmet legal needs can exacerbate health disparities and contribute to a lack of adherence to treatment plans and medical recommendations for care. Medical legal partnerships (MLPs) are integrated health care and legal aid interventions offered by many health systems in the United States. Although much research has been published regarding the success of MLPs with specific patient groups, there is a gap in literature regarding the nature of MLPs in a more general, at-risk patient population. OBJECTIVE: We aimed to better understand specific patient characteristics and health outcomes associated with different iHELP legal needs. DESIGN: This is a cross-sectional study of patients who were enrolled in the Delaware MLP (DMLP) from November 2018 to June 2020 (N = 212). SETTING: The DMLP is a collaboration between ChristianaCare, a Mid-Atlantic health system, and the Community Legal Aid Society, Inc (CLASI). PARTICIPANTS: Patients must be adults (ie, 18 years or older), below 200% of the federal poverty level (eg, ≤$53 000 for a household of 4 as of 2021), have at least one qualifying legal need, and live in the state. INTERVENTION: The DMLP is designed to address unmet legal needs that fall under a framework called iHELP. iHELP legal domains are income and insurance (i), housing and utilities (H), education and employment (E), legal status (L), and personal and family stability (P). MAIN OUTCOME MEASURES: Outcomes of interest were iHELP legal needs, patient demographics, perceived stress and mental and physical health-related quality of life, comorbidities, and health care utilization. RESULTS: Housing and utilities (46.2%) and income support (41.5%) were the highest reported legal needs. Perceived stress scores were significantly higher for those with income needs (P = .01) as well as those with housing and utilities needs (P = .01). CONCLUSIONS: MLP programs offer a value-added service that can address unmet legal needs in vulnerable, at-risk patients.

Creating a Nonprofit Spin-Off to Implement a Community Health Improvement Plan: A Case Study of a Midsize Health Department in the Midwest.

A common problem faced by local health departments is engaging cross-sector stakeholders to achieve shared community goals. Community engagement is critical for effective Community Health Improvement Plan (CHIP) development and implementation, while also being a standard for health department accreditation. This case study describes one city-county health department's development of a nonprofit arm to act as a catalyst for connecting community leaders to identify and collaboratively address community health goals. First, we describe our process to develop a nonprofit entity and strategically recruit community members to comprise the founding board of directors. Then, we describe methods employed by the nonprofit to create a community action plan in response to identified community health needs and how we incentivized progress. We evaluated our process using a mixed-methods approach and conclude that a nonprofit arm of a health department can be a novel strategy for effectively engaging community stakeholders to advance community health.

Psychosocial factors associated with dispositional hope, agency thinking, and pathways thinking in a homeless adult population.

Adults facing homelessness often perceive themselves to be at the bottom of society, which has implications for their current and future well-being. Snyder's hope theory, which posits that agency thinking and pathways thinking are necessary for achieving a hopeful outlook on life, may be helpful for understanding drivers of well-being among individuals experiencing homelessness. In this study, we examined dispositional hope, perceived goal attainment, social support, and perceived standing in society among 123 adults experiencing homelessness who were attending a support group at a daytime drop-in center in the United States. Participants completed self-report measures related to the aforementioned variables of interest. We discovered that higher levels of self-reported goal attainment, independent of the type of goal identified, were significantly associated with total hope and both its subscales, that social support was significantly associated with total hope and pathways thinking, and that perceived standing in society was significantly associated with total hope and agency thinking.

Facilitators and challenges in the adoption of a virtual nurse visit in the home health setting.

The COVID-19 pandemic created an opportunity to incorporate nurse-led virtual home care visits into heart failure patients' plan of care. As a supplemental nurse visit to traditional in-person home visits, the Virtual Nurse Visit (VNV) service was deployed using Zoom teleconferencing technology enabling telehealth nurses to remotely communicate, assess, and educate their patients. This mixed methods study explored heart failure patients' abilities, experience, and satisfaction to use and adopt a virtual nurse visit. Sociodemographic, semi-structured interview questions, and the System Usability Scale data were collected. Thirty-four participants completed the study. Over half of participants perceived the VNV usable and four qualitative themes emerged: perceived safety during COVID-19, preferences for care delivery, user experiences and challenges, and satisfaction with the VNV service. Findings from this study builds the science around telehealth that will inform future studies examining this type of nurse-led virtual visit and subsequent patient outcomes.

The effect of the food environment on fresh produce served in family child care homes.

BACKGROUND: Higher produce consumption in childhood decreases risks of short- and long-term malnutrition, obesity, and disease. Children in early care programs, including family child care homes (FCCHs), receive 50-67% of daily nutrition while in care. Procuring nutritious foods requires grocer access, which is absent in food deserts (FDs). AIM: To determine if FCCH food environment (FE) impacted distance to grocers and amount of fresh produce served. METHODS: Using a cross-sectional design, Modified Retail Food Environment Index scores determined census tract FD status. FCCH and grocer addresses were geocoded and distance to the nearest grocers was calculated. Fresh produce was observed during two lunches. RESULTS: FE did not influence distance to grocers or fresh produce served. Non-desert FCCHs tended to serve fresh produce more frequently. The amount of fresh produce served was overall low. CONCLUSION: Further studies are warranted to inform policies aimed to reduce provider barriers regarding service of fresh produce.

Impact of a Healthy Retail Intervention on Fruits and Vegetables and Total Sales in Tribally Owned Convenience Stores: Findings From the THRIVE Study.

BACKGROUND: Healthy retail interventions are a recommended intervention strategy to address diet-related diseases, such as obesity and diabetes; however, retail managers are concerned about their bottom line. This study's aim was to assess the impact of a healthy retail intervention on fruits and vegetables (FV) sales, as well as total sales, in tribally owned convenience stores where grocery stores are scarce. METHOD: We analyzed weekly sales data over the first 6 months of a healthy retail intervention. We assessed the proportion of sales from two FV baskets. The FV basket included all fresh, canned, and dried FV sold at stores; while the fruits, vegetables, and salads (FVS) basket included all FV items as well as all salads sold. We compared mean weekly sales rates in intervention and control stores over the 6-month period using generalized estimating equations models to account for repeated measures. RESULTS: Mean weekly FV basket sales rates were higher in intervention stores than control stores in both Nations. Mean weekly FVS baskets sales were significantly higher in intervention stores than control stores in one Nation and were higher, but not statistically significant, in intervention stores in the other Nation. Total sales remained steady throughout the intervention period. CONCLUSIONS: The THRIVE (Tribal Health and Resilience in Vulnerable Environments) intervention increased FV sales without negatively affecting total sales. Policy and Practice Implications. Healthy retail interventions in tribal convenience stores, where many Native Americans living in rural areas shop due to scarcity of grocery stores, could improve diet-related disparities without reducing total sales.

A Nutrition Environment Measure to Assess Tribal Convenience Stores: The THRIVE Study.

In rural American Indian (AI) communities, where supermarkets are rare, tribally owned and operated convenience stores are an important food source. Food environment measures for these settings are needed to understand and address the significant diet-related disparities among AIs. Through a tribal-university partnership that included tribal health and commerce representatives from two Native Nations in rural southeastern Oklahoma, we developed the Nutrition Environment Measures Survey for Tribal Convenience Stores (NEMS-TCS) to inform the development and evaluation of a healthy food retail intervention. The NEMS-TCS assessed four scored domains of the rural convenience store food environment-food availability, pricing, quality, and placement-and included 11 food categories that emphasized ready-to-eat food items. Trained raters administered the NEMS-TCS using a sample of 18 rural convenience stores (primarily ranging between 2,400 and 3,600 square feet). We assessed interrater reliability with kappa statistics for dichotomized variables and intraclass correlation coefficients (ICC) for continuous variables. NEMS-TCS demonstrated high inter-rater reliability for all food categories (>85% agreement), subscores (ICC = 0.73-1.00), and the total score (ICC = 0.99). The NEMS-TCS responds to recent calls for reliable measures for rural food environments and may be valuable for studying food environments of large convenience stores in other Native Nations as well as other rural settings.

Diabetes among Hispanics in Oklahoma: Assessing Disparities to Guide Basic and Applied Research.

Background ­: Diabetes, a leading cause of morbidity and mortality in the United States, disproportionally affects minority populations. In 2015, Hispanics, the largest minority in the country, had the third highest rate of diabetes prevalence and the third highest age-adjusted rate of diabetes-related mortality. Substantial progress in understanding diabetes disparities nationally and in many areas of the country has been made. However, little is known about diabetes and related mortality among Hispanics in Oklahoma, which is known as a Hispanic "new Settlement" state due to the relatively recent and substantial growth of this population. Methods ­: We used Oklahoma Behavioral and Risk Factor Surveillance Survey data (2011-2016) to calculate population estimates of diabetes prevalence and selected sociodemographic characteristics for Hispanic and Non-Hispanic adults in the state. We used Oklahoma Death Registry data to estimate diabetes-related mortality rates for Hispanic and Non-Hispanic adults for the same five-year period. We examined differences in diabetes prevalence and diabetes-related mortality across selected sociodemographic characteristics. Results ­: Hispanics are the largest minority group in Oklahoma. Spanish is the most common non-English language spoken in the state. Hispanics are younger, poorer, less educated and experience less access to health care compared to other populations in Oklahoma. While Hispanics had the fifth highest reported diabetes prevalence rate during the five-year period examined, they had the third highest diabetes-related mortality rate in the state. Discussion and Conclusions ­: There is a need for community engagement and basic and applied research to help identify and reduce diabetes disparities in the growing Hispanic population in Oklahoma.

A Healthy Retail Intervention in Native American Convenience Stores: The THRIVE Community-Based Participatory Research Study.

Objectives. To assess a healthy retail intervention in Tribal convenience stores in Oklahoma.Methods. We adapted healthy retail strategies to the context of 8 Tribally owned stores. We assessed individual- and store-level outcomes in a cluster-controlled intervention trial (April 2016-June 2017). We measured fruit and vegetable intake, store environment perceptions, and purchases before and after the intervention among a cohort of 1637 Native American shoppers. We used mixed-effects linear regression to estimate pre- to postintervention changes in and between groups.Results. We followed 74% of participants (n = 1204) 9 to 12 months. Intervention and control participants perceived healthier stores after intervention. Higher shopping frequency was related to purchases of fruits, vegetables, and healthy items.Conclusions. Intervention exposure was associated with healthy purchasing but not fruit and vegetable intake. Research is needed to further assess impacts of environmental interventions on intake.Public Health Implications. As the first healthy retail intervention in Tribally owned stores, our results contribute evidence for environmental and policy interventions to address obesity in Tribal Nations. Multicomponent interventions, led by Tribal leaders from diverse sectors, are needed to create healthy environments and sustainable improvements in Native American health.

Food choice considerations among American Indians living in rural Oklahoma: The THRIVE study.

In rural American Indian (AI) communities, access to affordable, healthy foods is often limited. Understanding AI food choice considerations when selecting foods, such as sensory appeal, cost, or health, is an important yet understudied topic for eliminating persistent AI health disparities. In partnership with the Chickasaw Nation and Choctaw Nation of Oklahoma, we administered a modified version of the Food Choice Values (FCV) Questionnaire to a cross-sectional sample of 83 AI patrons shopping at tribally-owned convenience stores ≥3 times per week. The FCV Questionnaire uses 25 items to assess eight FCV subscales related to buying and eating food, including sensory appeal; safety; accessibility; convenience; health/weight control; organic; tradition; and comfort. We compared mean scores for each FCV subscale by demographic groups using t-tests and ANOVA. We used confirmatory factor analysis (CFA) to examine how well the data from this population fit FCV subscale constructs. We then used cluster analysis, MANOVA, and discriminant analysis to characterize distinct segments of the population based on patterns of FCV endorsement. Appeal, safety, and access FCVs were most strongly endorsed across the sample. Prioritization of FCVs varied by age, gender, income, and education. Our cluster analysis identified four groups, or segments, each with distinct patterns of FCV endorsement: limited endorsement of any FCVs (23.3%); safety and sensory appeal (32.9%); health/weight control (17.8%); and broad endorsement of FCVs (26.0%). These groups varied by age and employment status. Findings from this analysis informed the design and implementation of a healthy retail intervention comprised of new healthful foods and beverages, product placement and marketing strategies within four tribally-owned and operated convenience stores. Public health interventions aimed at reducing nutrition-related disparities in rural AI populations may benefit from assessing food choice considerations.

Food Insecurity and Chronic Diseases Among American Indians in Rural Oklahoma: The THRIVE Study.

OBJECTIVES: To examine food insecurity and cardiovascular disease-related health outcomes among American Indians (AIs) in rural Oklahoma. METHODS: We surveyed a cross-sectional sample of 513 AI adults to assess food insecurity domains (i.e., food quality and quantity) and obesity, diabetes, and hypertension. RESULTS: Among AIs surveyed, 56% reported inadequate food quantity and 62% reported inadequate food quality. The unadjusted prevalence of diabetes (28.4% vs 18.4%), obesity (60.0% vs 48.3%), and hypertension (54.1% vs 41.6%) was higher among participants with inadequate food quantity than among those with adequate food quantity. These associations did not reach statistical significance after adjustment for age, gender, study site, education, and income. The unadjusted prevalence of obesity (60.7% vs 45.8%), diabetes (27.3% vs 18.8%), and hypertension (52.5% vs 42.5%) was higher among those with inadequate food quality than among those with adequate food quality, even after adjustment for age, gender, study site, education, and income. CONCLUSIONS: Tribal, federal, and state policymakers, as well as businesses and nonprofit organizations, must collaboratively take aggressive action to address food insecurity and its underlying causes, including improving tribal food environments, reducing barriers to healthy foods, and increasing living wages.

Pancreatic Cancer: A Survival Analysis Study in Oklahoma.

BACKGROUND: Pancreatic cancer is among the most deadly cancers. Risk factors associated with the disease include age, race, sex, smoking status, and diabetes status. METHOD: We conducted a prospective analysis of risk factors and length of survival among pancreatic cancer patients living in Oklahoma between 1997 and 2012 (n=6,291). Kaplan-Meier survival curves were created followed by the log-rank test to compare difference in the survival time. Cox proportional hazard regression models were used to examine the strength of association through the estimated hazard ratios. RESULTS: The median survival time of the cohort was three months. Significant risk factors for reduced survival times included age, stage at diagnosis, and year of diagnosis. CONCLUSION: Results are in agreement with previous research findings. There have been small but noteworthy improvements in survival times for pancreatic cancer patients in Oklahoma. Length of survival during the study period was significantly associated with known risk factors such as age and stage of diagnosis.

National study of chronic disease self-management: 6-month and 12-month findings among cancer survivors and non-cancer survivors.

OBJECTIVE: This study examined the applicability of the Stanford Chronic Disease Self-Management Program (CDSMP) for cancer survivors and compared outcomes among cancer survivors and participants with other chronic diseases (non-cancer survivors). METHODS: Participants were older adults (n = 1170) enrolled in the National Study of CDSMP. Detailed information about physical and psychosocial health status and health and healthcare behaviors was collected from participants (n = 116 cancer survivors and n = 1054 non-cancer survivors) via self-report before CDSMP participation and at 6-month and 12-month follow-ups. Linear and generalized linear mixed models were used to assess baseline-to-6-month and baseline-to-12-month changes. RESULTS: Among cancer survivors, general health, depression, and sleep significantly improved from baseline to 6 months. These significant changes were sustained at 12 months. Communication with physician, medication compliance, pain, days in poor physical health, days in poor mental health, and days kept from usual activities and physical activity also improved significantly from baseline to 12 months. Among non-cancer survivors, all outcomes except medication compliance and stress improved significantly from baseline to 6 months. At 12 months, medication compliance also improved significantly. CONCLUSIONS: Findings suggest that participation in CDSMP, an evidence-based chronic disease self-management intervention not specifically tailored for cancer survivorship, may significantly improve physical and psychosocial health status and key health and healthcare behaviors among cancer survivors. Additional research is needed to elucidate cancer survivors' unique needs and examine the benefits of tailored versions of CDSMP. Nevertheless, CDSMP, available at scale nationally and internationally, is a promising intervention for cancer survivors and should be considered a valuable component of survivorship care.

The effect of India's total sanitation campaign on defecation behaviors and child health in rural Madhya Pradesh: a cluster randomized controlled trial.

BACKGROUND: Poor sanitation is thought to be a major cause of enteric infections among young children. However, there are no previously published randomized trials to measure the health impacts of large-scale sanitation programs. India's Total Sanitation Campaign (TSC) is one such program that seeks to end the practice of open defecation by changing social norms and behaviors, and providing technical support and financial subsidies. The objective of this study was to measure the effect of the TSC implemented with capacity building support from the World Bank's Water and Sanitation Program in Madhya Pradesh on availability of individual household latrines (IHLs), defecation behaviors, and child health (diarrhea, highly credible gastrointestinal illness [HCGI], parasitic infections, anemia, growth). METHODS AND FINDINGS: We conducted a cluster-randomized, controlled trial in 80 rural villages. Field staff collected baseline measures of sanitation conditions, behaviors, and child health (May-July 2009), and revisited households 21 months later (February-April 2011) after the program was delivered. The study enrolled a random sample of 5,209 children <5 years old from 3,039 households that had at least one child <24 months at the beginning of the study. A random subsample of 1,150 children <24 months at enrollment were tested for soil transmitted helminth and protozoan infections in stool. The randomization successfully balanced intervention and control groups, and we estimated differences between groups in an intention to treat analysis. The intervention increased percentage of households in a village with improved sanitation facilities as defined by the WHO/UNICEF Joint Monitoring Programme by an average of 19% (95% CI for difference: 12%-26%; group means: 22% control versus 41% intervention), decreased open defecation among adults by an average of 10% (95% CI for difference: 4%-15%; group means: 73% intervention versus 84% control). However, the intervention did not improve child health measured in terms of multiple health outcomes (diarrhea, HCGI, helminth infections, anemia, growth). Limitations of the study included a relatively short follow-up period following implementation, evidence for contamination in ten of the 40 control villages, and bias possible in self-reported outcomes for diarrhea, HCGI, and open defecation behaviors. CONCLUSIONS: The intervention led to modest increases in availability of IHLs and even more modest reductions in open defecation. These improvements were insufficient to improve child health outcomes (diarrhea, HCGI, parasite infection, anemia, growth). The results underscore the difficulty of achieving adequately large improvements in sanitation levels to deliver expected health benefits within large-scale rural sanitation programs. TRIAL REGISTRATION: ClinicalTrials.gov NCT01465204. Please see later in the article for the Editors' Summary.

Wage theft as a neglected public health problem: an overview and case study from San Francisco's Chinatown District.

Wage theft, or nonpayment of wages to which workers are legally entitled, is a major contributor to low income, which in turn has adverse health effects. We describe a participatory research study of wage theft among immigrant Chinatown restaurant workers. We conducted surveys of 433 workers, and developed and used a health department observational tool in 106 restaurants. Close to 60% of workers reported 1 or more forms of wage theft (e.g., receiving less than minimum wage [50%], no overtime pay [> 65%], and pay deductions when sick [42%]). Almost two thirds of restaurants lacked required minimum wage law signage. We discuss the dissemination and use of findings to help secure and enforce a wage theft ordinance, along with implications for practice.

Studying and addressing urban immigrant restaurant worker health and safety in San Francisco's Chinatown district: a CBPR case study.

With its emphasis on empowerment, individual and community capacity building, and translating research findings into action, community-based participatory research (CBPR) may be particularly advantageous in work with urban immigrant populations. This paper highlights eight ways in which CBPR has been shown to add value to work with urban underserved communities. It then describes the background, context, and methods of an ecological CBPR project, the Chinatown Restaurant Worker Health and Safety Study, conducted in San Francisco, California, and draws on study processes and outcomes to illustrate each of the eight areas identified. Challenges of using CBPR, particularly with urban immigrant populations, briefly are described, drawing again on the Chinatown study to provide illustrative examples. We discuss lessons learned, through this and other studies, for the effective use of CBPR with urban immigrant populations. We conclude that despite its challenges, this transdisciplinary, community-partnered and action-oriented approach to inquiry can make substantial contributions to both the processes and the outcomes of the research.