Novel Health Information Technology to Aid Provider Recognition and Treatment of Major Depressive Disorder and Posttraumatic Stress Disorder in Primary Care.

BACKGROUND: Millions of traumatized refugees worldwide have resettled in the United States. For one of the largest, the Cambodian community, having their mental health needs met has been a continuing challenge. A multicomponent health information technology screening tool was designed to aid provider recognition and treatment of major depressive disorder and posttraumatic stress disorder (PTSD) in the primary care setting. METHODS: In a clustered randomized controlled trial, 18 primary care providers were randomized to receive access to a multicomponent health information technology mental health screening intervention, or to a minimal intervention control group; 390 Cambodian American patients empaneled to participating providers were assigned to the providers' randomized group. RESULTS: Electronic screening revealed that 65% of patients screened positive for depression and 34% screened positive for PTSD. Multilevel mixed effects logistic models, accounting for clustering structure, indicated that providers in the intervention were more likely to diagnose depression [odds ratio (OR), 6.5; 95% confidence interval (CI), 1.48-28.79; P=0.013] and PTSD (OR, 23.3; 95% CI, 2.99-151.62; P=0.002) among those diagnosed during screening, relative to the control group. Providers in the intervention were more likely to provide evidence-based guideline (OR, 4.02; 95% CI, 1.01-16.06; P=0.049) and trauma-informed (OR, 15.8; 95% CI, 3.47-71.6; P<0.001) care in unadjusted models, relative to the control group. Guideline care, but not trauma-informed care, was associated with decreased depression at 12 weeks in both study groups (P=0.003), and neither was associated with PTSD outcomes at 12 weeks. CONCLUSIONS: This innovative approach offers the potential for training primary care providers to diagnose and treat traumatized patients, the majority of whom seek mental health care in primary care (ClinicalTrials.gov number, NCT03191929).

Asthma coalition effects on vulnerable sub groups of children: the most frequent users of health care and the youngest.

OBJECTIVE: To examine the impact of Allies Against Asthma, community-based coalitions working to improve asthma outcomes, on vulnerable children: those with the most urgent health care use and those of youngest age. METHODS: Allies zip codes were matched with comparison communities on demographic factors. Five years of Medicaid data (n = 26,836) for significant health care events: hospitalizations, ED and urgent care facility visits, were analyzed. Longitudinal analyses using generalized estimating equations and proportional hazards models compared Allies and comparison group children. RESULTS: In the two start-up years of Allies, odds of having a significant event were greater for Allies children than for comparison children (p < 0.05). During the third and fourth years when Allies activities were fully implemented, for frequent health care users at baseline, odds of an asthma event were the same for both Allies and comparison children, yet in the less frequent users, odds of an event were lower in Allies children (p < 0.0001). In the initial year of Allies efforts, among the youngest, the Allies children had greater odds than comparison children of an event (p < 0.01), but by the fourth year the Allies group had lower odds (p = 0.02) of an event. Hazard ratios over all years of the study for the youngest Allies children and most frequent baseline users of urgent care were lower than for comparison children (p = 0.01 and p = 0.0004). CONCLUSION: Mobilizing a coalition of diverse stakeholders focused on policy and system change generated community-wide reductions over the long-term in health care use for vulnerable children.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative.

OBJECTIVES: We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS: Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS: In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS: Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

Policy and system change and community coalitions: outcomes from allies against asthma.

OBJECTIVES: We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. METHODS: We interviewed a sample of 1477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. RESULTS: A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. CONCLUSIONS: Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.

Global goods movement and the local burden of childhood asthma in southern California.

OBJECTIVES: As part of a community-based participatory research effort, we estimated the preventable burden of childhood asthma associated with air pollution in the southern California communities of Long Beach and Riverside. METHODS: We calculated attributable fractions for 2 air pollution reduction scenarios to include assessment of the newly recognized health effects associated with residential proximity to major roads and impact from ship emissions. RESULTS: Approximately 1600 (9%) of all childhood asthma cases in Long Beach and 690 (6%) in Riverside were attributed to traffic proximity. Ship emissions accounted for 1400 (21%) bronchitis episodes and, in more modest proportions, health care visits for asthma. Considerably greater reductions in asthma morbidity could be obtained by reducing nitrogen dioxide and ozone concentrations to levels found in clean coastal communities. CONCLUSIONS: Both Long Beach and Riverside have heavy automobile traffic corridors as well as truck traffic and regional pollution originating in the Los Angeles-Long Beach port complex, the largest in the United States. Community-based quantitative risk analyses can improve our understanding of health problems and help promote public health in transportation planning.

A Health Profile and Overview of Healthcare Experiences of Cambodian American Refugees and Immigrants Residing in Southern California.

Asian Americans are understudied in health research and often aggregated into one homogenous group, thereby disguising disparities across subgroups. Cambodian Americans, one of the largest refugee communities in the United States, may be at high risk for adverse health outcomes. This study compares the health status and healthcare experiences of Cambodian American refugees and immigrants. Data were collected via questionnaires and medical records from two community clinics in Southern California (n = 308). Chi square and t-tests examined the socio-demographic differences between immigrants and refugees, and ANCOVA models compared the mean differences in responses for each outcome, adjusting for age at immigration, education level, and clinic site. Cambodian American refugees reported overall lower levels of health-related quality of life (all p's < 0.05 in unadjusted models) and self-rated health [unadjusted means (SD) = 18.2 (16.8) vs. 21.7 (13.7), p < 0.05], but either similar or more positive healthcare experiences than Cambodian American immigrants. In adjusted analyses, refugees had higher rates of diabetes and cardiovascular disease risk (e.g. heart condition and hypertension; p's < 0.05) compared to Cambodian American immigrants. There were minimal differences in self-reported health behaviors between the two groups. There is a need for more health promotion efforts among Cambodian American refugees and immigrants to improve their health outcomes and perceived wellbeing.

Engaging the community in coalition efforts to address childhood asthma.

For health improvement efforts to effectively address community needs, community members must be engaged in planning and implementing public health initiatives. For Allies Against Asthma's coalitions, the community included not only the subpopulation of individuals who suffer disproportionately from asthma but also the individuals and institutions that surround them. Through a quantitative self-assessment survey, informal discussion among coalition leadership, and interviews with key informants, data relevant to community engagement identified a number of important ways the Allies coalitions approached community involvement. Respondents' comments made clear that the way the coalitions conduct their work is often as important as what they do. Across coalitions, factors that were identified as important for community involvement included (a) establishing a commitment to community involvement, (b) building trust, (c) making participation feasible and comfortable, (d) responding to community identified needs, (e) providing leadership development opportunities, and (f) building a shared commitment to desired outcomes.

Coalition-based approaches for addressing environmental issues in childhood asthma.

Outdoor air pollution and the indoor environment have been shown to cause or exacerbate childhood asthma. Allies Against Asthma coalitions implemented a broad range of activities to reduce or remediate indoor exposure to asthma environmental triggers for children with asthma including education and trigger remediation, physician and other health care provider education, and policy efforts to improve air quality in homes and schools. Outdoor environmental triggers were addressed through programs to increase education and awareness and efforts to change policies related to environmental conditions. Implementation of such efforts was complicated by the lack of safe and affordable housing and the amount of time and resources necessary to address policy change. Keys to success included promoting coordination and partnerships among coalition members, implementation of consistent messages, and building a broad and unified voice for policy change.

Rationale and study protocol for a multi-component Health Information Technology (HIT) screening tool for depression and post-traumatic stress disorder in the primary care setting.

The prevalence rate of depression in primary care is high. Primary care providers serve as the initial point of contact for the majority of patients with depression, yet, approximately 50% of cases remain unrecognized. The under-diagnosis of depression may be further exacerbated in limited English-language proficient (LEP) populations. Language barriers may result in less discussion of patients' mental health needs and fewer referrals to mental health services, particularly given competing priorities of other medical conditions and providers' time pressures. Recent advances in Health Information Technology (HIT) may facilitate novel ways to screen for depression and other mental health disorders in LEP populations. The purpose of this paper is to describe the rationale and protocol of a clustered randomized controlled trial that will test the effectiveness of an HIT intervention that provides a multi-component approach to delivering culturally competent, mental health care in the primary care setting. The HIT intervention has four components: 1) web-based provider training, 2) multimedia electronic screening of depression and PTSD in the patients' primary language, 3) Computer generated risk assessment scores delivered directly to the provider, and 4) clinical decision support. The outcomes of the study include assessing the potential of the HIT intervention to improve screening rates, clinical detection, provider initiation of treatment, and patient outcomes for depression and post-traumatic stress disorder (PTSD) among LEP Cambodian refugees who experienced war atrocities and trauma during the Khmer Rouge. This technology has the potential to be adapted to any LEP population in order to facilitate mental health screening and treatment in the primary care setting.

Policy and system change and community coalitions: outcomes from allies against asthma.

Objectives. We assessed policy and system changes and health outcomes produced by the Allies Against Asthma program, a 5-year collaborative effort by 7 community coalitions to address childhood asthma. We also explored associations between community engagement and outcomes. Methods. We interviewed a sample of 1,477 parents of children with asthma in coalition target areas and comparison areas at baseline and 1 year to assess quality-of-life and symptom changes. An extensive tracking and documentation procedure and a survey of 284 participating individuals and organizations were used to ascertain policy and system changes and community engagement levels. Results. A total of 89 policy and system changes were achieved, ranging from changes in interinstitutional and intrainstitutional practices to statewide legislation. Allies children experienced fewer daytime (P = .008) and nighttime (P = .004) asthma symptoms than comparison children. In addition, Allies parents felt less helpless, frightened, and angry (P = .01) about their child's asthma. Type of community engagement was associated with number of policy and system changes. Conclusions. Community coalitions can successfully achieve asthma policy and system changes and improve health outcomes. Increased core and ongoing community stakeholder participation rather than a higher overall number of participants was associated with more change.