Feasibility of Implementing Disability Inclusive Evidence-Based Health Promotion.

People with disabilities face a number of barriers to accessing and participating in evidence-based health promotion programs offered within the community. To address these barriers, the program implementation process needs to integrate disability inclusion throughout planning and implementation. The National Center on Health, Physical Activity and Disability's inclusive Community Implementation Process (NiCIP) provides a framework for implementers to systematically integrate strategies into their health promotion programs that increase inclusion while maintaining the fidelity the program. The NiCIP is a community-engaged process that brings key stakeholders together to guide the selection and implementation of data-driven solutions that promote inclusion in, and access to, health promotion programs. In this article, we first provide an overview of the NiCIP. Then, we present a case study exploring one community's experience using the NiCIP to implement a disability inclusive nutrition program within their community.

Redefining Exposure: Using Mobile Technology and Geospatial Analysis to Explore When and Where Chicago Adolescents are Exposed to Neighborhood Characteristics.

Differences in how individuals navigate and interact with physical space have clear implications for when and where they are exposed to environmental characteristics. To address this reality, we propose and test a novel method with a sample of Chicago adolescents that links individual GPS coordinates with locations of environmental characteristics as a strategy to increase precision in the measurement of environmental exposures. We use exposure to violent crime as an example and link the GPS coordinates of 51 youth collected over a one-week period during the summer of 2016 to locations and times of violent crime. We explore different spatial and temporal parameters to determine whether an exposure occurred. Using the 660-foot (201 m), 24-hour operationalization, we found that youth were exposed to a total of 126 violent crimes, with an average of 3.82 (SD = 3.24) per respondent. This was higher than the 12 that were identified when exposure was calculated as the number of violent crimes occurring within 660 feet (201 m) of youths' residential addresses during the week-long assessment period. Examining correlations between the different exposure variables and measures of youths' psychological functioning, we found the largest relationships when using the GPS-based indices. We present a strategy for measuring exposure to environmental characteristics using GPS data. Higher rates of crime exposure are found based on GPS coordinates than with residential address. GPS-based exposure measures are related to youths' psychological functioning.

Does the built environment moderate the relationship between having a disability and lower levels of physical activity? A systematic review.

The relationship between the built environment and physical activity has been well documented. However, little is known about how the built environment affects physical activity among people with disabilities, who have disproportionately higher rates of physical inactivity and obesity. This study is the first systematic review to examine the role of the built environment as a moderator of the relationship between having a disability (physical, sensory or cognitive) and lower levels of physical activity. After conducting an extensive search of the literature published between 1990 and 2015, 2039 articles were screened, 126 were evaluated by abstract and 66 by full text for eligibility in the review. Data were abstracted using a predefined coding guide and synthesized from both qualitative and quantitative studies to examine evidence of moderation. Nine quantitative and six qualitative articles met the inclusion criteria. Results showed that most research to date has been on older adults with physical disabilities. People with disabilities described how aspects of the built environment affect neighborhood walking, suggesting a positive moderating role of features related to safety and aesthetic qualities, such as benches, lighting and stop light timing. There were mixed results among studies that examined the relationship quantitatively. Most of the studies were not designed to appropriately examine moderation. Future research should utilize valid and reliable built environment measures that are more specific to disability and should include people with and without disabilities to allow for testing of moderation of the built environment.

Development of a community health inclusion index: an evaluation tool for improving inclusion of people with disabilities in community health initiatives.

BACKGROUND: Community health initiatives often do not provide enough supports for people with disabilities to fully participate in healthy, active living opportunities. The purpose of this study was to design an instrument that focused on integrating disability-related items into a multi-level survey tool that assessed healthy, active living initiatives. METHODS: The development and testing of the Community Health Inclusion Index (CHII) involved four components: (a) literature review of studies that examined barriers and facilitators to healthy, active living; (b) focus groups with persons with disabilities and professionals living in geographically diverse settings; (c) expert panel to establish a final set of critical items; and (d) field testing the CHII in 164 sites across 15 communities in 5 states to assess the instrument's reliability. RESULTS: Results from initial analysis of these data indicated that the CHII has good reliability. Depending on the subscale, Cronbach's alpha ranged from 0.700 to 0.965. The CHII's inter-rater agreement showed that 14 of the 15 venues for physical activity or healthy eating throughout a community had strong agreement (0.81 - 1.00), while one venue had substantial agreement (0.61 - 0.80). CONCLUSION: The CHII is the first instrument to operationalize community health inclusion into a comprehensive assessment tool that can be used by public health professionals and community coalitions to examine the critical supports needed for improving healthy, active living among people with disabilities.

Quantifying active travel among people with disabilities in the US.

BACKGROUND: People with disabilities have higher rates of physical inactivity than people without. Active travel (e.g., walking/wheeling to nearby destinations or transit) is a recommended approach to increasing total physical activity (PA) but limited research has examined active travel among people with disabilities. OBJECTIVE: To describe active travel among a nationally representative sample of people with disabilities, analyze variation between sub-groups, and examine factors associated with active travel. METHODS: Using the 2017 National Household Travel Survey, our cross-sectional analysis summarized counts and duration of walking/wheeling trips for people with four different types of disabilities. We examined which factors were associated with doing any active travel and the duration of active travel, using zero inflated negative binomial regression models. RESULTS: Our analysis identified that 14.55% of people with disabilities took a mean of 2.56 (95%CI = 2.42-2.69) walking/wheeling trips per day. Compared to non-active travelers, a higher proportion of active travelers were low-income, lived alone, had no-vehicle, and were Black or Hispanic. For active travelers, daily walking minutes, on average, were 46.41 (95%CI = 40.25-52.57) among people who used ambulatory devices, 41.55 (95%CI = 24.61-58.49) among people who were blind/low-vision, 39.93 (95%CI = 35.41-44.45) among people who used no device, and 29.58 (95%CI = 23.53-35.64) among people who used chair devices. Our analysis identified individual, household, and community factors associated with the likelihood and duration of walking/wheeling for travel and variation across disability types. CONCLUSIONS: Understanding the multiple identities of active travelers with disabilities can inform walking/wheeling intervention strategies. Infrastructure improvements that support less reliance on automobiles could increase active travel among people with disabilities.

Reflection on the application of the Consolidated Framework for Implementation Research to a national policy to improve inclusion of people with disabilities.

People with disabilities face many barriers in the built environment impacting their mobility, health, and social participation. In the US, under the Americans with Disabilities Act (ADA), municipalities were required to develop and implement barrier-removal plans for pedestrian infrastructure, called ADA transition plans, but very few have done so. Many communities know they need a plan but do not know how to get it done because of a lack of understanding of the many different implementation considerations. Implementation science offers a useful approach for understanding complex policy implementation such as ADA plans. This paper provides a reflection on the adaptation of the Consolidated Framework for Implementation Research (CFIR) to evaluate the implementation of ADA transition planning. To apply the CFIR, we tailored the construct definitions and modified them to fit the specific context of the ADA transition planning process. We documented the constructs that were more challenging to apply, those that were not relevant, and those that were particularly useful. This paper can serve as a valuable example that other researchers can use when considering adapting the CFIR or other implementation frameworks for the evaluation of complex social policy beyond the ADA.

The PhenX Toolkit: Recommended Measurement Protocols for Social Determinants of Health Research.

Health disparities are driven by unequal conditions in the environments in which people are born, live, learn, work, play, worship, and age, commonly termed the Social Determinants of Health (SDoH). The availability of recommended measurement protocols for SDoH will enable investigators to consistently collect data for SDoH constructs. The PhenX (consensus measures for Phenotypes and eXposures) Toolkit is a web-based catalog of recommended measurement protocols for use in research studies with human participants. Using standard protocols from the PhenX Toolkit makes it easier to compare and combine studies, potentially increasing the impact of individual studies, and aids in comparability across literature. In 2018, the National Institute on Minority Health and Health Disparities provided support for an initial expert Working Group to identify and recommend established SDoH protocols for inclusion in the PhenX Toolkit. In 2022, a second expert Working Group was convened to build on the work of the first SDoH Working Group and address gaps in the SDoH Toolkit Collections. The SDoH Collections consist of a Core Collection and Individual and Structural Specialty Collections. This article describes a Basic Protocol for using the PhenX Toolkit to select and implement SDoH measurement protocols for use in research studies. © 2024 The Authors. Current Protocols published by Wiley Periodicals LLC. This article has been contributed to by U.S. Government employees and their work is in the public domain in the USA. Basic Protocol: Using the PhenX Toolkit to select and implement SDoH protocols.

COVID-19 Cases and Deaths in Skilled Nursing Facilities in Cook County, Illinois.

OBJECTIVE: The COVID-19 pandemic has had a devastating impact on older adults residing in skilled nursing facilities. This study examined the pathways through which community and facility factors may have affected COVID-19 cases and deaths in skilled nursing facilities. METHODS: We used structural equation modeling to examine the number of COVID-19 cases and deaths in skilled nursing facilities in Cook County, Illinois, from January 1 through September 30, 2020. We used data from the Centers for Medicare & Medicaid Services, the Illinois Department of Public Health, and the Cook County Medical Examiner's Office to determine the number of resident COVID-19 cases and deaths, number of staff cases, facility-level characteristics, and community-level factors. RESULTS: Poorer facility quality ratings and higher numbers of staff COVID-19 cases were associated with increased numbers of resident COVID-19 cases and deaths. For-profit ownership was associated with larger facilities and higher resident-to-staff ratios, which increased the number of staff COVID-19 cases. Furthermore, skilled nursing facilities with a greater percentage of White residents were in areas with lower levels of social vulnerability and were less likely to be for-profit and, thus, were associated with higher quality. CONCLUSIONS: For-profit ownership was associated with lower facility quality ratings and increases in the number of staff COVID-19 cases, leading to increased resident COVID-19 cases and deaths. Establishing enforceable regulations to ensure quality standards in for-profit skilled nursing facilities is critical to prevent future outbreaks and reduce health disparities in facilities serving racial and ethnic minority populations.

Reply to "industry-informed perspectives on the benefits of rideshare-based medical transportation".

The authors of "Rideshare Transportation to Health Care: Evidence From a Medicaid Implementation" respond to a letter to the editor.

Development of a Predictive Algorithm to Identify Adults With Mobility Limitations Using VA Health Care Administrative Data.

An estimated 31.5 million Americans have a mobility limitation. Health care administrative data could be a valuable resource for research on this population but methods for cohort identification are lacking. We developed and tested an algorithm to reliably identify adults with mobility limitation in U.S. Department of Veterans Affairs health care data. We linked diagnosis, encounter, durable medical equipment, and demographic data for 964 veterans to their self-reported mobility limitation from the Medicare Current Beneficiary Survey. We evaluated performance of logistic regression models in classifying mobility limitation. The binary approach (yes/no limitation) had good sensitivity (70%) and specificity (79%), whereas the multilevel approach did not perform well. The algorithms for predicting a binary mobility limitation outcome performed well at discriminating between veterans who did and did not have mobility limitation. Future work should focus on multilevel approaches to predicting mobility limitation and samples with greater proportions of women and younger adults.

Evaluation of the Reaching People with Disabilities through Healthy Communities Project.

BACKGROUND: People with disabilities experience disparities in chronic diseases, such as obesity, heart disease, and diabetes, in disproportionate numbers. Research suggests that healthy communities initiatives that work to implement policy, systems and environmental (PSE) changes can help reduce these disparities by improving access to healthy choices for community residents with disabilities. However, healthy communities efforts to implement PSE changes are often not inclusive of people with disabilities. OBJECTIVE: The purpose of this paper is to evaluate the implementation of an Inclusive Healthy Communities Model that was designed to reach people with disabilities through inclusive PSE changes. METHODS: Professionals from local public health agencies and disability organizations in 10 diverse communities worked to infuse disability inclusion into PSE changes promoting healthy living. Data on PSE implementation was collected and coded into categories to describe the nature of the inclusive PSEs. RESULTS: Communities implemented 507 inclusive PSEs, 466 of which were environmental changes, 25 systems changes, and 16 policy changes. A large majority of PSEs were related to improving the built environment to facilitate access to public spaces, such as parks, playgrounds, and community gardens. Many communities also implemented policy and systems changes related to the addition of inclusion into existing policies, community plans, and ongoing training of staff. CONCLUSION: Integrating disability inclusion into traditional healthy communities efforts can facilitate improved access and opportunity for healthy living among people with disabilities. This pilot project has implications for public health workforce training, current practices, and PSE development with interdisciplinary teams and multisectoral coalitions.

Combining Accelerometer and GPS Features to Evaluate Community Mobility in Knee Ankle Foot Orthoses (KAFO) Users.

Orthotic and assistive devices such as knee ankle foot orthoses (KAFO), come in a variety of forms and fits, with several levels of available features that could help users perform daily activities more naturally. However, objective data on the actual use of these devices outside of the research lab is usually not obtained. Such data could enhance traditional lab-based outcome measures and inform clinical decision-making when prescribing new orthotic and assistive technology. Here, we link data from a GPS unit and an accelerometer mounted on the orthotic device to quantify its usage in the community and examine the correlations with clinical metrics. We collected data from 14 individuals over a period of 2 months as they used their personal KAFO first, and then a novel research KAFO; for each device we quantified number of steps, cadence, time spent at community locations and time wearing the KAFO at those locations. Sensor-derived metrics showed that mobility patterns differed widely between participants (mean steps: 591.3, SD =704.2). The novel KAFO generally enabled participants to walk faster during clinical tests ( ∆6 Minute-Walk-Test=71.5m, p=0.006). However, some participants wore the novel device less often despite improved performance on these clinical measures, leading to poor correlation between changes in clinical outcome measures and changes in community mobility ( ∆6 Minute-Walk-Test - ∆ Community Steps: r=0.09, p=0.76). Our results suggest that some traditional clinical outcome measures may not be associated with the actual wear time of an assistive device in the community, and obtaining personalized data from real-world use through wearable technology is valuable.

The 2019 Conference on Health and Active Transportation: Research Needs and Opportunities.

Active transportation (AT) is widely viewed as an important target for increasing participation in aerobic physical activity and improving health, while simultaneously addressing pollution and climate change through reductions in motor vehicular emissions. In recent years, progress in increasing AT has stalled in some countries and, furthermore, the coronavirus (COVID-19) pandemic has created new AT opportunities while also exposing the barriers and health inequities related to AT for some populations. This paper describes the results of the December 2019 Conference on Health and Active Transportation (CHAT) which brought together leaders from the transportation and health disciplines. Attendees charted a course for the future around three themes: Reflecting on Innovative Practices, Building Strategic Institutional Relationships, and Identifying Research Needs and Opportunities. This paper focuses on conclusions of the Research Needs and Opportunities theme. We present a conceptual model derived from the conference sessions that considers how economic and systems analysis, evaluation of emerging technologies and policies, efforts to address inclusivity, disparities and equity along with renewed attention to messaging and communication could contribute to overcoming barriers to development and use of AT infrastructure. Specific research gaps concerning these themes are presented. We further discuss the relevance of these themes considering the pandemic. Renewed efforts at research, dissemination and implementation are needed to achieve the potential health and environmental benefits of AT and to preserve positive changes associated with the pandemic while mitigating negative ones.

Rideshare transportation to health care: evidence from a Medicaid implementation.

OBJECTIVES: Some managed care companies are testing rideshare services as an approach to providing transportation to health care for Medicaid enrollees. The objective of this study was to assess whether more rideshare transportation to health care was associated with improved self-reported ride experiences and fewer late/failed passenger pickups for Medicaid enrollees. STUDY DESIGN: We surveyed a random sample of Medicaid enrollees in a northwestern US state on their experiences with nonemergency medical transportation (NEMT) in the past year. We linked survey responses to administrative data on NEMT utilization from the state's transportation broker to obtain an objective measure of rideshare utilization. METHODS: We used bivariate tests and multivariable logistic regressions to examine associations between enrollee perspectives on the quality of and access to health care and rideshare use, defined as none, some, or many NEMT trips through rideshare services. RESULTS: More than 35% of respondents received NEMT from rideshare services at least once. Perceptions of the ride experience, driver, and vehicle did not differ based on the proportion of rideshare trips received. Having more rideshare trips was associated with reporting late and failed pickups. In multivariable regression, the statistical significance held for failed pickups. Sensitivity analyses showed similar results. CONCLUSIONS: This study suggests that rideshare to health care programs can meet similar goals of quality compared with traditional NEMT services but may have implications for health care access for Medicaid enrollees. Future evaluations need to include the perspectives of enrollees and explore potential differences among different Medicaid subpopulations.

Changing the Paradigm in Public Health and Disability through a Knowledge Translation Center.

People with disabilities are a health disparity population that face many barriers to health promotion opportunities in their communities. Inclusion in public health initiatives is a critical approach to address the health disparities that people with disabilities experience. The National Center on Health, Physical Activity and Disability (NCHPAD) is tackling health disparities in the areas of physical activity, healthy nutrition, and healthy weight management. Using the NCHPAD Knowledge Adaptation, Translation, and Scale-up Framework, NCHPAD is systematically facilitating, monitoring, and evaluating inclusive programmatic, policy, systems, and environmental (PPSE) changes in communities and organizations at a local and national level. Through examples we will highlight the importance of adapting knowledge, facilitating uptake, developing strategic partnerships and building community capacity that ultimately creates sustainable, inclusive change.

Geographic access to dental care varies in Missouri and Wisconsin.

OBJECTIVE: To examine geographic access to dental providers for the general population and children with public insurance in Missouri and Wisconsin. METHODS: Using a newly constructed dentist office database from the American Dental Association master file and other sources, we use the two-step floating area catchment area method to calculate population to provider ratios at the census block group level. These ratios are used to determine potential geographic dentist shortage areas. We utilize street network data to estimate travel times and catchment areas between population centers and dental offices. This methodology accounts for the actual spatial distribution of dental providers and potential dental patients. RESULTS: Within and across Missouri and Wisconsin, there is some variation in geographic access to dental offices for the general population and publicly insured children. More than 90 percent of publicly insured children have access to dental providers within 30 minutes. Among the states examined, Missouri has more geographic disparities to dental care. CONCLUSION: The Health Resources and Services Administration, which designates dental health professional shortage areas, relies on administrative boundaries to calculate population to dental provider ratios. These boundaries may not reflect actual or "real-time" dental care markets. The methods employed in this paper may give policymakers a template to better determine geographic dentist shortage areas.

Global position sensing and step activity as outcome measures of community mobility and social interaction for an individual with a transfemoral amputation due to dysvascular disease.

BACKGROUND AND PURPOSE: Community mobility of individuals following lower limb amputation is highly variable and has a great impact on their quality of life. Currently, clinical assessments of ambulatory ability and motivation influence prosthetic prescription. However, these outcome measures do not effectively quantify community mobility (ie, mobility outside of the clinic) of individuals with an amputation. Advances in global positioning systems (GPSs) and other wearable step-monitoring devices allow for objective, quantifiable measurement of community mobility. This case report will examine the combined use of a GPS unit and a step activity monitor to quantify community mobility and social interaction of an individual with transfemoral amputation due to dysvascular disease. CASE DESCRIPTION: A 76-year-old woman with a unilateral transfemoral amputation due to vascular disease carried a commercial GPS unit and step activity monitor to quantify her community mobility and social interaction every day over a period of 1 month. The step activity monitor was affixed to her prosthesis. The patient used a wheelchair as well as her prosthesis for everyday mobility. OUTCOME: Information from the GPS unit and step activity monitor provided quantitative details on the patient's steps taken in and out of the home, wheelchair use, prosthesis use, driving trips, and time spent on social and community trips. DISCUSSION: This case report describes a potential clinical measurement procedure for quantifying community mobility and social interaction of an individual with lower limb amputation. Future efforts are needed to validate this measurement tool on large sample sizes and in individuals with different mobility levels. Additionally, automatization of data analysis and technological approaches to reduce compromised GPS signals may eventually lead to a practical, clinically useful tool.