Effectiveness of implementing evidence-based approaches to promote physical activity in a Midwestern micropolitan area using a quasi-experimental hybrid type I study design.

BACKGROUND: Much evidence-based physical activity (PA) interventions have been tested and implemented in urban contexts. However, studies that adapt, implement, and evaluate the effectiveness of these interventions in micropolitan rural contexts are needed. The study aimed to evaluate the effectiveness of the Active Ottumwa intervention to promote PA in a micropolitan community. METHODS: Between 2013 - 2019, we implemented Active Ottumwa in a micropolitan setting, and subsequently implemented and evaluated its effectiveness using a Hybrid Type I design. In this paper, we describe the intervention's effectiveness in promoting PA. We collected PA data over 24 months from a cohort of community residents using accelerometers and PA data from two cross-sectional community surveys administered in 2013 and 2018, using the Global Physical Activity Questionnaire. RESULTS: From the cohort, we found significant change in PA over 24 months (P = 0.03) corresponding to a 45-min daily decrease in sedentary activity, a daily increase of 35-min in light PA and 9 min in moderate-to-vigorous PA. There was a statistically significant (P = 0.01) increasing trend at the population-level in the moderate-to-vigorous composition of 7 min between the two cross-sectional assessments (95% CI: 0.1%-1.34%). CONCLUSIONS: The study demonstrates that the adapted evidence-based PA interventions in a micropolitan context is effective.

Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study.

STUDY OBJECTIVE: To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs). METHODS: Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence. RESULTS: A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86). CONCLUSION: Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.

Building Leadership, Capacity, and Power to Advance Health Equity and Justice through Community-Engaged Research in the Midwest.

The Health Equity Advancement Lab (HEAL) at the University of Iowa College of Public Health began in 2012 to support students, researchers, and community members interested in tackling persistent health inequities through a community-based participatory research (CBPR) approach. Using concepts from critical consciousness theory, we developed an approach to building students', faculty members', and community partners' capacity to engage in CBPR to promote health equity that involved immersion in developing CBPR projects. Our paper describes the evolution of HEAL as a facilitating structure that provides a support network and engages diverse stakeholders in critical reflection as they participate in research to advance health equity, and resulting political efficacy and social action. We describe one HEAL-affiliated research project that employs a CBPR approach and has a strong focus on providing transformative learning experiences for students, faculty, and community members. We highlight challenges, successes, and lessons learned in the application of critical consciousness as a framework that engages diverse academic and community partners seeking to promote health equity. We argue that critical consciousness is a relevant theoretical framework to promote transformative learning among students, faculty, and community partners to promote health equity research in diverse communities.

Assessing the national capacity for disaster research response (DR2) within the NIEHS Environmental Health Sciences Core Centers.

INTRODUCTION: Disaster research response (DR2) is necessary to answer scientific questions about the environmental health impacts of disasters and the effectiveness of response and recovery strategies. This research explores the preparedness and capacity of National Institute of Environmental Health Sciences (NIEHS) P30 Core Centers (CCs) to conduct DR2 and engage with communities in the context of disasters. METHODS: In early 2018, we conducted an online survey of CC Directors (n = 16, 69.5% response rate) to identify their DR2 relevant scientific assets, capabilities, and activities. Summary statistics were calculated. We also conducted in-depth, semi-structured interviews with 16 (69.5%) CC Community Engagement Core directors to identify facilitators and barriers of DR2 community engagement. Interview notes were coded and thematically analyzed. RESULTS: Survey: While 56% of responding CCs reported prior participation in DR2 and preparedness to repurpose funding to support DR2, less than one third reported development of a disaster-specific data collection protocol, deployment plan, or concept of operations plan, participation in an exercise to test DR2 capacity, development of academic partnerships to conduct DR2, development of a process for fast-tracking institutional review board approvals for DR2, or maintenance of formal agreements with state, local, or community-based partner(s). A number of CCs reported developing or considering developing capacity in these areas. Barriers to, and tools and resources to enhance, CC engagement in DR2 were identified. Interviews: Four key components for community engaged DR2 were identified: pre-existing community relationships, responsive research that benefits communities, coordination among researchers, and coordination with community response partners. Several roles for, benefits of, and barriers to Community Engagement Rapid Response Teams (CERRT) were described. CONCLUSIONS: CCs have significant scientific assets and community partnerships that can be leveraged for DR2; however, additional planning is necessary to ensure that these scientific assets and community partnerships are leveraged when disasters strike.

A qualitative assessment of the smoking policies and cessation activities at smaller workplaces.

BACKGROUND: To reduce the negative consequences of smoking, workplaces have adopted and implemented anti-smoking initiatives. Compared to large workplaces, less research exists about these initiatives at smaller workplaces, which are more likely to hire low-wage workers with higher rates of smoking. The purpose of this study was to describe and compare the smoking policies and smoking cessation activities at small (20-99 employees) and very small (< 20 employees) workplaces. METHODS: Thirty-two key informants coming from small and very small workplaces in Iowa completed qualitative telephone interviews. Data collection occurred between October 2016 and February 2017. Participants gave descriptions of the anti-smoking initiatives at their workplace. Additional interview topics included questions on enforcement, reasons for adoption, and barriers and facilitators to adoption and implementation. The data were analyzed using counts and content and thematic analysis. RESULTS: Workplace smoking policies were nearly universal (n = 31, 97%), and most workplaces (n = 21, 66%) offered activities to help employees quit smoking. Reasons for adoption included the Iowa Smokefree Air Act, to improve employee health, and organizational benefits (e.g., reduced insurance costs). Few challenges existed to adoption and implementation. Commonly cited facilitators included the Iowa Smokefree Air Act, no issues with compliance, and support from others. Compared to small workplaces, very small workplaces offered cessation activities less often and had fewer tobacco policy restrictions. CONCLUSIONS: This study showed well-established tobacco control efforts in small workplaces, but very small workplaces lagged behind. To reduce potential health disparities in smoking, future research and intervention efforts in tobacco control should focus on very small workplaces.

Human Papillomavirus Vaccination in the United States: Uneven Uptake by Gender, Race/Ethnicity, and Sexual Orientation.

OBJECTIVES: To assess national differences in human papillomavirus (HPV) vaccine uptake among young adults in the United States by gender, race/ethnicity, and sexual orientation. METHODS: We tested group differences in initiation and completion of the HPV vaccine series (i.e., 3 doses) by Rao-Scott χ(2) test among 6444 respondents aged 18 to 30 years from the 2013 National Health Interview Survey. RESULTS: Among men, 5% reported receiving the HPV vaccine, with no differences in uptake by race/ethnicity or sexual orientation. By contrast, 30% of the women reported receiving the HPV vaccine, with women of color having lower odds of initiating and completing the vaccine series compared with White women. CONCLUSIONS: In the United States, HPV vaccine rates are lagging in men and show disparities among women. Increasing HPV vaccine uptake and series completion among women of color and all men may provide considerable long-term public health benefits.

Provider-to-provider telemedicine for sepsis is used less frequently in communities with high social vulnerability.

PURPOSE: Sepsis disproportionately affects patients in rural and socially vulnerable communities. A promising strategy to address this disparity is provider-to-provider emergency department (ED)-based telehealth consultation (tele-ED). The objective of this study was to determine if county-level social vulnerability index (SVI) was associated with tele-ED use for sepsis and, if so, which SVI elements were most strongly associated. METHODS: We used data from the TELEmedicine as a Virtual Intervention for Sepsis in Rural Emergency Department study. The primary exposures were SVI aggregate and component scores. We used multivariable generalized estimating equations to model the association between SVI and tele-ED use. FINDINGS: Our study cohort included 1191 patients treated in 23 Midwestern rural EDs between August 2016 and June 2019, of whom 326 (27.4%) were treated with tele-ED. Providers in counties with a high SVI were less likely to use tele-ED (adjusted odds ratio [aOR] = 0.51, 95% confidence interval [CI] 0.31‒0.87), an effect principally attributable to the housing type and transportation component of SVI (aOR = 0.44, 95% CI 0.22-0.89). Providers who treated fewer sepsis patients (1‒10 vs. 31+ over study period) and therefore may have been less experienced in sepsis care, were more likely to activate tele-ED (aOR = 3.91, 95% CI 2.08‒7.38). CONCLUSIONS: Tele-ED use for sepsis was lower in socially vulnerable counties and higher among providers who treated fewer sepsis patients. These findings suggest that while tele-ED increases access to specialized care, it may not completely ameliorate sepsis disparities due to its less frequent use in socially vulnerable communities.

Staying cool in a changing climate: Reaching vulnerable populations during heat events.

The frequency and intensity of hot weather events are expected to increase globally, threatening human health, especially among the elderly, poor, and chronically ill. Current literature indicates that emergency preparedness plans, heat health warning systems, and related interventions may not be reaching or supporting behavior change among those most vulnerable in heat events. Using a qualitative multiple case study design, we comprehensively examined practices of these populations to stay cool during hot weather ("cooling behaviors") in four U.S. cities with documented racial/ethnic and socio-economic disparities and diverse heat preparedness strategies: Phoenix, Arizona; Detroit, Michigan; New York City, New York; and Philadelphia, Pennsylvania. Based on semi-structured in-depth interviews we conducted with 173 community members and organizational leaders during 2009-2010, we assessed why vulnerable populations do or do not participate in health-promoting behaviors at home or in their community during heat events, inquiring about perceptions of heat-related threats and vulnerability and the role of social support. While vulnerable populations often recognize heat's potential health threats, many overlook or disassociate from risk factors or rely on experiences living in or visiting warmer climates as a protective factor. Many adopt basic cooling behaviors, but unknowingly harmful behaviors such as improper use of fans and heating and cooling systems are also adopted. Decision-making related to commonly promoted behaviors such as air conditioner use and cooling center attendance is complex, and these resources are often inaccessible financially, physically, or culturally. Interviewees expressed how interpersonal, intergenerational relationships are generally but not always protective, where peer relationships are a valuable mechanism for facilitating cooling behaviors among the elderly during heat events. To prevent disparities in heat morbidity and mortality in an increasingly changing climate, we note the implications of local context, and we broadly inform heat preparedness plans, interventions, and messages by sharing the perspectives and words of community members representing vulnerable populations and leaders who work most closely with them.

A life course perspective on stress and health among caregivers of children with asthma in Detroit.

Low-income caregivers raising children with asthma experience many obstacles to their own health, including stress. To understand and describe their daily experiences, researchers conducted 40 qualitative interviews supplemented with descriptive quantitative surveys in Detroit, Michigan, as part of a community-based participatory research partnership of Community Action Against Asthma. Prevalence of chronic illness is noticeably higher among participants than the general US population. Caregivers identified stress processes that may influence disproportionate health outcomes and risk-related behaviors over their lifetime. Applying a life course perspective, findings suggest that public health interventions should address family-level comorbidities, increase instrumental social support, and acknowledge practical coping mechanisms.

Climate change and health: indoor heat exposure in vulnerable populations.

INTRODUCTION: Climate change is increasing the frequency of heat waves and hot weather in many urban environments. Older people are more vulnerable to heat exposure but spend most of their time indoors. Few published studies have addressed indoor heat exposure in residences occupied by an elderly population. The purpose of this study is to explore the relationship between outdoor and indoor temperatures in homes occupied by the elderly and determine other predictors of indoor temperature. MATERIALS AND METHODS: We collected hourly indoor temperature measurements of 30 different homes; outdoor temperature, dewpoint temperature, and solar radiation data during summer 2009 in Detroit, MI. We used mixed linear regression to model indoor temperatures' responsiveness to weather, housing and environmental characteristics, and evaluated our ability to predict indoor heat exposures based on outdoor conditions. RESULTS: Average maximum indoor temperature for all locations was 34.85°C, 13.8°C higher than average maximum outdoor temperature. Indoor temperatures of single family homes constructed of vinyl paneling or wood siding were more sensitive than brick homes to outdoor temperature changes and internal heat gains. Outdoor temperature, solar radiation, and dewpoint temperature predicted 38% of the variability of indoor temperatures. CONCLUSIONS: Indoor exposures to heat in Detroit exceed the comfort range among elderly occupants, and can be predicted using outdoor temperatures, characteristics of the housing stock and surroundings to improve heat exposure assessment for epidemiological investigations. Weatherizing homes and modifying home surroundings could mitigate indoor heat exposure among the elderly.

Congruence between urban adolescent and caregiver responses to questions about the adolescent's asthma.

In clinical and research settings, it is increasingly acknowledged that adolescents may be better positioned than their caregivers to provide information in regard to their own health status, including information related to asthma. Very little is known, however, about the congruence between adolescent and caregiver responses to questions about asthma beyond reports of symptoms. We analyzed data for 215 urban, primarily African-American adolescent-caregiver pairs. Adolescents and caregiver reports concerning the adolescent's asthma-related medical history were moderately correlated and not found to differ at the aggregate level. Correlations between adolescent and caregiver reports of the adolescent's asthma symptoms and functional status were weak, although these differences deteriorated at the aggregate level. Adolescent-caregiver reports of symptoms and functioning were more likely to be in agreement if the adolescent was older, if school personnel were unaware of the child's asthma, and if the adolescent's asthma was classified as mild intermittent. For questions concerning the frequency of hospitalizations, emergency department visits, and physician visits, moderate correlations between adolescent and caregiver responses were noted, although with some differences at the aggregate level. Findings suggest that, when adolescents and their caregivers are asked about the adolescent's asthma in clinical and research settings, the extent to which the two perspectives are likely to agree depends on the type of information sought. Clinicians and researchers may obtain more accurate information if questions about symptoms and functional status are directed toward adolescents.

'Stuck in the quagmire of an HIV ghetto': the meaning of stigma in the lives of older black gay and bisexual men living with HIV in New York City.

In this paper, we analyse the life history narratives of 10 poor gay and bisexual Black men over the age of 50 living with HIV/AIDS in New York City, focusing on experiences of stigma. Three overarching themes are identified. First, participants described the ways in which stigma marks them as 'just one more body' within social and medical institutions, emphasising the dehumanisation they experience in these settings. Second, respondents described the process of 'knowing your place' within social hierarchies as a means through which they are rendered tolerable. Finally, interviewees described the dynamics of stigma as all-consuming, relegating them to the 'quagmire of an HIV ghetto'. These findings emphasise that despite advances in treatment and an aging population of persons living with HIV, entrenched social stigmas continue to endanger the well-being of Black men who have sex with men.

TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study).

Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.

Blowing the whistle: what do African American adolescents with asthma and their caregivers understand by "wheeze?".

AIMS: To investigate what African American adolescents with asthma and their caregivers understand by "wheeze". METHODS: Caregivers (n = 35) and adolescents (n = 35) were each asked to describe what they understood by "wheeze". Respondents were also shown a video clip of an adolescent wheezing and asked: a) to describe the breathing of the adolescent in the video; and, b) whether the adolescent respondent's breathing had ever been similar to the video-presented symptoms. RESULTS: Most caregivers described wheeze in terms of sound alone (61.8%) while the majority of adolescents described wheeze as something that is felt (55.8%). Few caregivers and adolescents (5.8% each) included "whistling" in their descriptions of "wheeze". Most caregivers and adolescents used the word "wheeze" when describing the video clip, but nearly one-quarter of the caregivers and one-third of the adolescents felt that the adolescent's breathing was never similar to the video. CONCLUSION: Caregiver and adolescents descriptions of wheeze are different from each other and both may be different from clinical definitions of the term. Study findings have implications for the ways in which questions about "wheeze" are framed and interpreted.

A typology of youth participation and empowerment for child and adolescent health promotion.

Research suggests that increasing egalitarian relations between young people and adults is optimal for healthy development; however, the empirical assessment of shared control in youth-adult partnerships is emerging, and the field still requires careful observation, identification, categorization and labeling. Thus, our objective is to offer a conceptual typology that identifies degrees of youth-adult participation while considering the development potential within each type. We use an empowerment framework, rooted in evidence-based findings, to identify five types of youth participation: (1) Vessel, (2) Symbolic, (3) Pluralistic, (4) Independent and (5) Autonomous. The typology is constructed as a heuristic device to provide researchers, practitioners and policy-makers with a common language for articulating degrees of youth participation for optimal child and adolescent health promotion.

Community organizing network for environmental health: using a community health development approach to increase community capacity around reduction of environmental triggers.

The Community Organizing Network for Environmental Health (CONEH), a project of Community Action Against Asthma, used a community health development approach to improve children's asthma-related health through increasing the community's capacity to reduce physical and social environmental triggers for asthma. Three community organizers were hired to work with community groups and residents in neighborhoods in Detroit on the priority areas of air quality, housing, and citizen involvement in the environmental project and policy decision-making. As part of the evaluation of the CONEH project, 20 one-on-one semi-structured, in-depth interviews were conducted between August and November 2005 involving steering committee members, staff members, and key community organization staff and/or community members. Using data from the evaluation of the CONEH project, this article identifies the dimensions of community capacity that were enhanced as part of a CBPR community health development approach to reducing physical and social environmental triggers associated with childhood asthma and the factors that facilitated or inhibited the enhancement of community capacity.

The Interaction of Dopamine Genes and Financial Stressors to Predict Adulthood Intimate Partner Violence Perpetration.

Three dopamine genes (DAT1, DRD2, and DRD4) have been associated with interpersonal delinquency, aggression, and violence when individuals experience adverse environmental exposures. Guided by the catalyst model of aggression, risk alleles identified in previous studies were hypothesized to be associated with intimate partner violence (IPV) perpetration in the presence of financial stressors, a possible environmental trigger. This hypothesis was tested using weighted, clustered logistic regression with data from the National Longitudinal Study of Adolescent to Adult Health. The direct effects DAT1, DRD2, and DRD4 on IPV perpetration, and the interaction of DAT1, DRD2, and DRD4 and financial stressors on IPV perpetration were assessed. Due to cell size, only White men and women were included in this analysis. Increasing number of financial stressors was associated with increased odds of IPV perpetration, regardless of DAT1, DRD2, and DRD4 alleles. As predicted, increasing number of financial stressors was more strongly associated with IPV perpetration among individuals with high-risk DAT1 alleles, than individuals with low-risk alleles. However, this relationship was inverted for DRD2. Although there was still a significant interaction between DRD2 and financial stressors, individuals with low-risk alleles had higher odds of IPV perpetration in the presence of financial stressors. A similar, nonsignificant relationship was found for DRD4. These findings indicate that these genes may interact differently with environmental exposures and types of violent behavior. In addition, the findings may, if replicated, suggest dopamine plays a different role in IPV perpetration compared with other forms of aggression and violence.

Associations Between Organizational Culture, Workplace Health Climate, and Employee Smoking at Smaller Workplaces.

BACKGROUND: Smaller workplaces frequently employ low-wage earners, who have higher smoking rates. Organizational culture and workplace health climate are two characteristics that could influence employee smoking. The purpose of this study was to examine the associations between organizational culture, workplace health climate, and smoking among employees at small (20-99 employees) and very small (<20 employees) workplaces. We proposed the following hypotheses: a stronger clan culture will be associated with a better workplace health climate (HP1); a better workplace health climate will be associated with lower odds of current smoking (HP2); and there will be an association between workplace health climate and smoking intensity (HP3) and between workplace health climate and quit intention (HP4). METHODS: Executives and employees completed separate online questionnaires. Data collection occurred between June and October 2017. We used regression and Fisher's exact tests to answer study hypotheses. RESULTS: Workplaces with stronger clan cultures had a better workplace health climate (b = 0.27, P < .05), providing support for HP1. A better workplace health climate was associated with lower odds of being a current smoker (odds ratio [OR] = 0.08; 95% confidence interval [CI]: 0.01, 0.53), providing support for HP2. No significant relationship existed between workplace health climate and smoking intensity (P = .50) or between workplace health climate and intention to quit smoking (P = .32); therefore, HP3 and HP4 were not supported. CONCLUSION: Certain culture types may inform an organization's health climate. Despite a lower likelihood of current smoking in workplaces with better health climates, a better health climate may not be sufficient to produce changes in smoking behavior and intentions.

Establishing a Community-Based Participatory Research Partnership in a Rural Community in the Midwest.

BACKGROUND: Rural health disparities are well-documented. "New destination" communities in predominantly rural states have emerged in recent years, with immigrants moving into these communities for better opportunities. Few reports of community-based participatory partnerships with these communities have been previously described in the literature. OBJECTIVES: We report on the formation and implementation of a community-academic partnership to reduce health disparities in a rural Midwestern community. METHODS: We describe the creation of a partnership between the University of Iowa (UI) Prevention Research Center (PRC) and the Ottumwa, Iowa community. RESULTS: We describe the partnership formation, activities, and results of the implementation of the partnership, and challenges encountered, including balancing attention to different health disparities populations and ensuring mechanisms for hearing from the different voices in the community. CONCLUSIONS: Our experience suggests the importance and challenge of considering the multiple dimensions of health disparities in rural new destination Midwestern communities.