Data for Community Health Assessment in Rural Colorado: A Comparison of Electronic Health Records to Public Health Surveys to Describe Childhood Obesity.

CONTEXT: Community-level data are necessary to inform community health assessments and to plan for appropriate interventions. However, data derived from public health surveys may be limited or unavailable in rural locations. OBJECTIVE: We compared 2 sources of data for community health assessment in rural Colorado, electronic health records (EHRs) and routine public health surveys. DESIGN: Comparison of cross-sectional measures of childhood/youth obesity prevalence and data quality. SETTING: Two rural Colorado counties, La Plata and Prowers. PARTICIPANTS: The EHR cohort comprised patients 2 to 19 years of age who underwent a visit with the largest health care provider in each county. These data included sex, age, weight, height, race, ethnicity, and insurance status. Public health survey data were obtained from 2 surveys, the Colorado Child Health Survey (2-14 years of age) and the Healthy Kids Colorado Survey (15-19 years of age) and included caregiver and self-reported height and weight estimates. MAIN OUTCOME MEASURES: We calculated body mass index percentile for each patient and survey respondent and determined overweight/obesity prevalence by county. We evaluated data source quality indicators according to a rubric developed for this analysis. RESULTS: The EHR sample captured approximately 35% (n = 3965) and 70% (n = 2219) of all children living in La Plata and Prowers Counties, respectively. The EHR prevalence estimates of overweight/obesity were greater in precision than survey data in both counties among children 2 to 14 years of age. In addition, the EHR data were more timely and geographically representative than survey data and provided directly measured height and weight. Conversely, survey data were easier to access and more demographically representative of the overall population. CONCLUSIONS: Electronic health records describing the prevalence of obesity among children/youth living in rural Colorado may complement public health survey data for community health assessment and health improvement planning.

A Community-Engaged Approach to Collecting Rural Health Surveillance Data.

PURPOSE: In order for communities to make health-related, data-driven decisions concerning resource allocation, needed services, and intervention priorities, they need an accurate picture of the health status of residents. While state and national health surveillance systems exist to help local communities make data-driven health decisions, rural communities face unique challenges including: (1) limited county-level data; (2) underrepresented segments of the population; and (3) a lack of survey items to address local health concerns. The purpose of this study was to take a community-engaged approach to collecting population-based health status data in a rural area in an effort to address some of these unique challenges. METHODS: Using a community-based participatory research (CBPR) approach, over 1,500 residents from 6 rural and frontier counties were randomly selected with a stratified, multistage cluster study design. Surveys were primarily completed over the phone. FINDINGS: Response rates by county ranged from 59% to 80% (overall = 66%). Males and younger adults (18-24 year olds) were underrepresented in the sample, but Hispanics, low-income residents, and cell phone-only users were adequately represented. Prevalence rates for chronic disease and health behavior varied by county. CONCLUSIONS: The implications of this project are that engaging stakeholders in community surveillance efforts increases the quality, relevance and utility of the information collected and can help reach otherwise difficult-to-reach populations. This can result in a more accurate picture of the health status of residents, which can lead to making health-related, data-driven decisions concerning resource allocation, needed services, and intervention priorities.

Predicting arsenic concentrations in groundwater of San Luis Valley, Colorado: implications for individual-level lifetime exposure assessment.

Consumption of inorganic arsenic in drinking water at high levels has been associated with chronic diseases. Risk is less clear at lower levels of arsenic, in part due to difficulties in estimating exposure. Herein we characterize spatial and temporal variability of arsenic concentrations and develop models for predicting aquifer arsenic concentrations in the San Luis Valley, Colorado, an area of moderately elevated arsenic in groundwater. This study included historical water samples with total arsenic concentrations from 595 unique well locations. A longitudinal analysis established temporal stability in arsenic levels in individual wells. The mean arsenic levels for a random sample of 535 wells were incorporated into five kriging models to predict groundwater arsenic concentrations at any point in time. A separate validation dataset (n = 60 wells) was used to identify the model with strongest predictability. Findings indicate that arsenic concentrations are temporally stable (r = 0.88; 95 % CI 0.83-0.92 for samples collected from the same well 15-25 years apart) and the spatial model created using ordinary kriging best predicted arsenic concentrations (ρ = 0.72 between predicted and observed validation data). These findings illustrate the value of geostatistical modeling of arsenic and suggest the San Luis Valley is a good region for conducting epidemiologic studies of groundwater metals because of the ability to accurately predict variation in groundwater arsenic concentrations.

My baby, my move: examination of perceived barriers and motivating factors related to antenatal physical activity.

INTRODUCTION: Based on a socioecological model, the present study examined multilevel barriers and facilitators related to physical activity engagement during pregnancy in women of low socioeconomic status. METHODS: Individual and paired interviews were conducted with 25 pregnant women (aged 18-46 years, 17-40 weeks' gestation) to ask about motivational factors and to compare differences in activity level and parity. Atlas/Ti software was used to code verbatim interview transcripts by organizing codes into categories that reflect symbolic domains of meaning, relational patterns, and overarching themes. RESULTS: Perceived barriers and motivating factors differed between exercisers and nonexercisers at intrapersonal, interpersonal, and environmental levels. DISCUSSION: Future interventions should take into account key motivating multilevel factors and barriers to tailor more meaningful advice for pregnant women.

Early effects of the federally mandated Local Wellness Policy on school nutrition environments appear modest in Colorado's rural, low-income elementary schools.

To increase opportunities for healthy eating and physical activity, US school districts participating in the National School Lunch Program were required to create a Local Wellness Policy (LWP) by June 2006. The What's Working project described the initial influence of this mandate on nutrition environments and policies. In 2005 and 2007 (before and after the mandate went into effect), a survey about school features related to nutrition and physical activity was sent to a random sample of 45 low-income, rural elementary foodservice managers and principals. Schools averaged 204 students, 27% Hispanic. Districts' LWPs were coded for strength and comprehensiveness. In addition, key informant interviews were conducted with foodservice managers almost 2 years after the LWP went into effect. Three improvements were observed: increases in the percent of schools with policies stipulating predominantly healthy items be offered in classroom parties (21.4% in 2005 vs 48.7% in 2007), daily fresh fruit offerings in the lunchroom (0.80 choices in 2005 vs 1.15 choices in 2007), and the percent of schools using skinless poultry (27% in 2005 vs 59% in 2007). LWPs were weakly worded and rarely addressed energy content. Nutrition guideline elements most commonly addressed included vending machines, school stores, and à la carte food offerings. Seveny-three percent of foodservice managers were familiar with their district's LWP but did not perceive it changed lunchroom practices. Although LWPs offer a framework to support opportunities for healthy eating, few evidence-based practices were implemented as a direct result of the mandate. Schools need more information about evidence-based practices, as well as technical and financial assistance for implementation.

Early impact of the federally mandated Local Wellness Policy on physical activity in rural, low-income elementary schools in Colorado.

The What's Working project described the initial impact of the United States' federally mandated Local Wellness Policy in rural, low-income elementary schools located in Colorado. Before and after the Local Wellness Policy mandate went into effect, a survey about school features related to nutrition and physical activity was sent to a random sample of 45 rural elementary schools (i.e., schools located outside of urban areas), in which at least 40% of students qualified for free or reduced-cost lunch. Overall, opportunities for physical activity did not change after the policy went into effect: although time in physical education increased by 14 min per week (P=0.10), time for recess decreased by roughly 19 min per week (P=0.10). Policies supporting student participation in physical education and recess (an unstructured time during school hours when students are allowed to play outside) did not change. The researchers coded Local Wellness Policies and found them to have weak wording that produced minimal impact. Content analysis of key informant interviews suggested several barriers to the impact of the Local Wellness Policies: (1) competing pressures facing school districts, (2) lack of resources devoted to the Local Wellness Policy, (3) principals' lack of knowledge about the policy, and (4) lack of accountability mechanisms to ensure policy implementation. Financial resources and more effective communication about Local Wellness Policies among school districts and principals are needed to elevate the importance of and increase opportunities for physical activity in rural, low-income Colorado elementary schools.