Measuring social determinants of health in the All of Us Research Program.

To accelerate medical breakthroughs, the All of Us Research Program aims to collect data from over one million participants. This report outlines processes used to construct the All of Us Social Determinants of Health (SDOH) survey and presents the psychometric characteristics of SDOH survey measures in All of Us. A consensus process was used to select SDOH measures, prioritizing concepts validated in diverse populations and other national cohort surveys. Survey item non-response was calculated, and Cronbach's alpha was used to analyze psychometric properties of scales. Multivariable logistic regression models were used to examine associations between demographic categories and item non-response. Twenty-nine percent (N = 117,783) of eligible All of Us participants submitted SDOH survey data for these analyses. Most scales had less than 5% incalculable scores due to item non-response. Patterns of item non-response were seen by racial identity, educational attainment, income level, survey language, and age. Internal consistency reliability was greater than 0.80 for almost all scales and most demographic groups. The SDOH survey demonstrated good to excellent reliability across several measures and within multiple populations underrepresented in biomedical research. Bias due to survey non-response and item non-response will be monitored and addressed as the survey is fielded more completely.

Life-Stage and Contextual Factors of Advance Care Planning Among Older Adults With Limited Income.

Patient perspectives are essential to understand healthcare disparities such as low rates of advance care planning (ACP) among adults with limited income. We completed twenty semi-structured interviews using purposive and snowball sampling. Initial and final themes emerged from inductive inclusion of recurring codes and deductive application of the cumulative disadvantage theory. Four themes emerged: (1) structural, (2) life-stage, (3) social stressors and resources, and (4) individual stress responses and ACP readiness. ACP resources among participants included positive structural and social support and previous familial death experiences that were mitigated by stress avoidance and competing priorities. Structural resources and healthcare stressors should be addressed with policy and research to improve continuous healthcare participation and support early, comprehensive ACP.

Assessing patient-level knowledge of precision medicine in a community health center setting.

As precision medicine approaches are implemented, cancer treatment decisions have come to require comprehension of genetic tests and their role in risk stratification and treatment options. Acceptance and implementation of precision medicine requires patient understanding of numeracy, genetic literacy, health literacy, and medical trust. Implementing precision medicine in a US federally qualified community health center (FQCHC) setting has received little attention. Using a mixed-methods approach, we sought to identify patient-level factors influencing the understanding of cancer risk and precision medicine among FQCHC patients. We enrolled 26 English-speaking adults aged 40-79 years. Participants enrolled in focus groups and completed surveys to assess patient-level understanding of precision medicine, numeracy, and health literacy. The majority of participants were female (77%) and self-identified as African American (89%). Approximately one-third reported having a high school degree or less. While health literacy was generally high, 42% felt that genes or genetics had little impact on health and most (69%) reported little familiarity with precision medicine. Many participants reported that trust in their providers was extremely or very important when receiving genetic tests. Numeracy levels were moderate, with nearly half reporting some discomfort working with fractions and 38% finding numerical information only occasionally useful. Findings suggest that patients may lack familiarity with precision medicine concepts relevant for understanding cancer treatment decisions. Future educational efforts may help bridge the gap in patient understanding and facilitate equitable opportunities for precision medicine for all patients, including those seeking care from community health centers.

Direct-to-patient telehealth equity: Reaching diverse pediatric populations in primary care.

INTRODUCTION: Telehealth is the use of electronic information and technology for long-distance clinical care. In direct-to-patient (DTP) telehealth, the patient initiates care from a personal computer or mobile device to a medical provider. While information on standard clinic-to-clinic telehealth exists, less is known about DTP telehealth in pediatric populations. Using quantitative and qualitative data, we examined DTP telehealth for low-income pediatric patient-families and compared the experience of English and non-English speakers. METHOD: Telehealth visits for acute and preventive care took place from April 2020 to May 2020 at a pediatric primary care clinic (80% Medicaid-insured, 40% non-English-speaking). Patients and primary care providers conducted the visit through the clinic's portal or other platforms (WhatsApp, FaceTime, Zoom). Providers completed an electronic survey with patient feedback about the telehealth experience and their own observations. An iterative inductive/deductive approach informed a coding scheme for free-text survey responses consisting of five domains. RESULTS: REDCap surveys were completed for 258 (52%) of telehealth visits. There was an overrepresentation of English visits compared to the overall clinic population and the majority of visits were via mobile phone. Visits with English speakers utilized the patient portal and had positive process ease ratings more often than those with non-English speakers. Providers rated most telehealth visits as satisfactory, with contributing elements including family call environment, technology process and experience, value added, and barriers. DISCUSSION: Expanding telehealth in pediatrics without worsening health disparities requires building digital health that is user-friendly on mobile technology, facilitating patient preferred language, and simplifying logistical processes. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Individual and neighborhood socioeconomic status and long-term individual trajectories of sleep duration among Black and White adults: the Southern Community Cohort Study.

STUDY OBJECTIVES: Sleep duration can change over the life course; however, previous studies rarely investigated the association between socioeconomic status (SES) and individual sleep trajectories over time. We examined the association between baseline socioeconomic characteristics and long-term sleep trajectories among Black and White adults. METHODS: This study used data from the Southern Community Cohort Study (N = 45 035). Diverse trajectories of sleep duration were constructed using self-reported sleep duration at baseline and after ~10 years of follow-up. The associations between baseline socioeconomic characteristics and sleep trajectories were examined using multinomial logistic regression. RESULTS: Both Black and White participants experienced similar long-term individual sleep trajectories for baseline educational attainment and employment status albeit the associations appeared stronger among White participants. Lower education and unemployment were associated with higher odds of various suboptimal sleep trajectories suggesting worsening long-term sleep patterns among both racial groups. However, there were some racial differences in the experience of long-term sleep trajectories for household income and neighborhood SES. Household income was notably more important among White than Black individuals; lower household income was associated with higher odds of more suboptimal long-term sleep trajectories for White than Black individuals. Also, neighborhood SES was slightly more important among White than Black individuals; lower neighborhood SES was associated with higher odds of a few suboptimal long-term sleep trajectories for both racial groups. CONCLUSIONS: Lower socioeconomic characteristics were associated with various suboptimal long-term sleep trajectories among Black and White participants. Substantial improvements in socio-economic characteristics may contribute to improved sleep patterns.

Association of Neighborhood Economic Trajectories With Changes in Weight Status Among Black and White Adults in the Southeastern US.

Importance: Neighborhood environment is an important factor associated with population disparities in obesity. However, few studies have examined whether and in what ways long-term trajectories of neighborhood conditions may be associated with weight outcomes. Moreover, there is a lack of research focusing on multidimensional and nuanced measures that make distinctions between multiple types of neighborhood change (eg, gentrification vs overall growth). Objective: To examine the association between long-term neighborhood economic trajectories and changes in weight status among Black and White adults residing in predominantly low-income communities in the southeastern US. Design, Setting, and Participants: This study was a longitudinal analysis of participants in the Southern Community Cohort Study. Five types of neighborhood economic trajectories (stability, growth, displacement, abandonment, and poverty concentration) were measured using data from the US Census and the American Community Survey from 2000 to 2016. Data were analyzed from December 12, 2021, to July 16, 2022. A total of 33 621 Black and White adults in the southeastern US were included in the analytic sample. Exposure: Neighborhood economic trajectory. Main Outcomes and Measures: Substantial weight gain and substantial weight loss (ie, gaining or losing ≥10% of baseline weight) between baseline (March 2002 to September 2009) and follow-up (November 2008 to January 2013) periods were assessed using self-reported information. Results: Among 33 621 participants, the mean (SD) age was 53.4 (8.8) years; 22 116 participants (65.8%) were women, 21 782 (64.8%) were Black, and 11 839 (35.2%) were White. Compared with residents in neighborhoods with stable trajectories, those in neighborhoods with growth trajectories that did not displace original residents were less likely to experience substantial weight gain (odds ratio [OR], 0.75; 95% CI, 0.58-0.97), whereas those in neighborhoods with poverty concentration trajectories were more likely to experience substantial weight gain (OR, 1.08; 95% CI, 1.00-1.17). These patterns appeared stronger among Black participants (eg, substantial weight gain in poverty concentration group: OR, 1.10 [95% CI, 1.00-1.22]; in growth group: OR, 0.76 [95% CI, 0.56-1.02]) compared with White participants (eg, substantial weight gain in poverty concentration group: OR, 1.03 [95% CI, 0.90-1.18]; in growth group: OR, 0.84 [95% CI, 0.52-1.36]). Differences in patterns were also observed among men (eg, substantial weight gain in poverty concentration group: OR, 1.02 [95% CI, 0.88-1.17]; in growth group: OR, 0.58 [95% CI, 0.35-0.96]) compared with women (eg, substantial weight gain in poverty concentration group: OR, 1.12 [95% CI, 1.02-1.23]; in growth group: OR, 0.83 [95% CI, 0.62-1.12]). However, none of the interaction terms between Black vs White participants and men vs women were statistically significant. Neighborhood trajectory was not associated with substantial weight loss (poverty concentration group: OR, 1.00 [95% CI, 0.93-1.09]; abandonment group: OR, 1.01 [95% CI, 0.84-1.15]; displacement group: OR, 1.04 [95% CI, 0.83-1.23]; growth group: OR, 0.88 [95% CI, 0.69-1.12]). Conclusions and Relevance: In this cohort study, neighborhood economic trajectories were associated with weight gain. These findings highlight the importance of using more nuanced and multidimensional measures of neighborhood change in public health research.

Gender differences in the experience of interstitial cystitis/bladder pain syndrome.

Aims: This study assessed gender differences in a debilitating urologic pain condition, interstitial cystitis/bladder pain syndrome (IC/BPS). We aimed to (1) evaluate how pain, symptom, and distress profiles of IC/BPS may differ between genders and (2) obtain in-depth firsthand accounts from patients to provide additional insight into their experiences that may explain potential gender differences. Methods: A mixed methods approach combined validated patient-reported outcome measures with a single timepoint 90-min focus group. Tests of summary score group differences between men and women were assessed across questionnaires measuring urologic symptoms, pain, emotional functioning, and diagnostic timeline. Qualitative analysis applied an inductive-deductive approach to evaluate and compare experiences of living with IC/BPS Group narratives were coded and evaluated thematically by gender using the biopsychosocial model, providing insight into the different context of biopsychosocial domains characterizing the male and female experience of IC/BPS. Results: Thirty-seven participants [women (n = 27) and men (n = 10)] completed measures and structured focus group interviews across eight group cohorts conducted from 8/2017 to 3/2019. Women reported greater pain intensity (p = 0.043) and extent (p = 0.018), but not significantly greater impairment from pain (p = 0.160). Levels of psychological distress were significantly elevated across both genders. Further, the duration between time of pain symptom onset and time to diagnosis was significantly greater for women than men (p = 0.012). Qualitative findings demonstrated key distinctions in experiences between genders. Men appeared not to recognize or to deter emotional distress while women felt overwhelmed by it. Men emphasized needing more physiological treatment options whilst women emphasized needing more social and emotional support. Interactions with medical providers and the healthcare system differed substantially between genders. While men reported feeling supported and involved in treatment decisions, women reported feeling dismissed and disbelieved. Conclusion: The findings indicate different pain experiences and treatment needs between genders in persons experiencing urologic pain and urinary symptoms, with potential intervention implications. Results suggest gender health inequality in medical interactions in this urologic population needing further investigation.

Qualitative analysis of COACH: A community-based behavioral intervention to reduce obesity health disparities within a marginalized community.

BACKGROUND: The purpose of this study was to conduct a qualitative evaluation of a behavioral intervention to prevent and treat childhood obesity in minority children. Using qualitative methods to augment understanding of intervention success may be one way to gain insight into the types of behavior change strategies that are most effective in childhood obesity interventions. METHODS: COACH was a randomized controlled trial of 117 Latino parent-child (ages 3-5) pairs in Nashville, TN that resulted in improved child BMI in intervention vs. control families at 1-year follow-up. All participant parents were invited to focus groups after the trial. Discussions were audiotaped, transcribed, and translated into English. A hierarchical coding scheme was generated, and qualitative analysis done using an inductive/deductive approach. Both theme saturation and consensus between the coders were achieved. Responses were compared between intervention and control groups. RESULTS: We conducted seven focus groups with 43 participants. 4 themes emerged from the intervention group: 1) perceived barriers to health behavior change; 2) strategies learned to overcome perceived barriers; 3) behavioral changes made in response to the program; and 4) knowledge, skills, and agency for family health behaviors. 4 themes emerged from the control group: 1) a desire to engage in health behaviors without specific strategies; 2) common set of barriers to health behavior change; 3) engagement in literacy activities, including creative problem-solving strategies; and 4) changes made in response to study visits. Analysis of coded data showed the intervention increased healthy behaviors (e.g., fruit/vegetable consumption) despite barriers (e.g., time, cost, culture, family dynamics). Intervention participants described using specific behavior change strategies promoted by the intervention including: substituting ingredients in culturally-normative recipes; avoiding grocery shopping when hungry; and coping with inability to meet goals with acceptance and problem-solving. Control participants reported little success in achieving healthy changes for their family. Intervention participants described successful health behavior changes that were shared across generations and were maintained after the program. Intervention participants reported increased awareness of their own agency in promoting their health. CONCLUSIONS: Qualitative evaluation of COACH provides a more detailed understanding of the intervention's quantitative effectiveness: child and adult health behaviors and personal agency were improved.

An academic, business, and community alliance to promote evidence-based public health policy: the case of primary seat belt legislation.

An academic, business, and community alliance comprising 285 organizations, including 43 national groups represented on a Blue Ribbon Panel organized by the U.S. Secretary of Transportation, targeted Arkansas, Florida, Mississippi, Minnesota, Tennessee, and Wisconsin for high involvement/intervention consisting of community organization and other political action to support passage of primary seat belt laws. State-level alliance activities began in January 2003. All six states enacted a primary seat belt law between 2004 and 2009. From January 2003 to May 2010, passage of primary legislation was 4.5 times as likely (95% CI 1.90, 10.68) in states with high versus low alliance involvement. Positive interaction between high alliance involvement and offers of federal incentives may have occurred as well. This evidence of success suggests that academic-business-community alliances for action to promote evidence-based public health policy may be effective.

Sedentary and physically active behavior patterns among low-income African-American and white adults living in the southeastern United States.

Increased sedentary behavior and lack of physical activity are associated with increased risk for many chronic diseases. Differences in leisure-time physical activity between African American and white adults have been suggested to partially explain racial disparities in chronic disease outcomes, but expanding the definition of physical activity to include household and occupational activities may reduce or even eliminate racial differences in total physical activity. The objective of this study was to describe patterns of active and sedentary behaviors in black and white adults and to examine these behaviors across demographic measures. Sedentary and physically active behaviors were obtained from a validated physical activity questionnaire in 23,021 black men, 9,899 white men, 32,214 black women, and 15,425 white women (age 40-79) at enrollment into the Southern Community Cohort Study. Descriptive statistics for sedentary time; light, moderate, and vigorous household/occupational activity; sports/exercise; total activity; and meeting current physical activity recommendations via sports/exercise were examined for each race-sex group. Adjusted means were calculated using multiple linear regression models across demographic measures. Study participants spent approximately 60% of waking time in sedentary behaviors. Blacks reported more television viewing time than whites (45 minutes for females, 15 minutes for males), but when sitting time was expressed as a proportion of overall awake time, minimal racial differences were found. Patterns of light, moderate, and vigorous household/occupational activity were similar in all race/sex groups. 2008 Physical Activity Guidelines for Americans were followed by 16% of women and 25% of men independent of race. Overall, black and white men and women in this study spent the majority of their daily time in sedentary behaviors and less than one-fourth followed current guidelines for physical activity. These results indicate that public health campaigns should focus on both reducing sedentary behavior and increasing physical activity in all adult US populations.

Evaluation of a questionnaire to assess sedentary and active behaviors in the Southern Community Cohort Study.

BACKGROUND: Low physical activity (PA) is linked to cancer and other diseases prevalent in racial/ethnic minorities and low-income populations. This study evaluated the PA questionnaire (PAQ) used in the Southern Cohort Community Study, a prospective investigation of health disparities between African-American and white adults. METHODS: The PAQ was administered upon entry into the cohort (PAQ1) and after 12-15 months (PAQ2) in 118 participants (40-60 year-old, 48% male, 74% African-American). Test-retest reliability (PAQ1 versus PAQ2) was assessed using Spearman correlations and the Wilcoxon signed rank test. Criterion validity of the PAQ was assessed via comparison with a PA monitor and a last-month PA survey (LMPAS), administered up to 4 times in the study period. RESULTS: The PAQ test-retest reliability ranged from 0.25-0.54 for sedentary behaviors and 0.22-0.47 for active behaviors. The criterion validity for the PAQ compared with PA monitor ranged from 0.21-0.24 for sedentary behaviors and from 0.17-0.31 for active behaviors. There was general consistency in the magnitude of correlations between the PAQ and PA-monitor between African-Americans and whites. CONCLUSIONS: The SCCS-PAQ has fair to moderate test-retest reliability and demonstrated some evidence of criterion validity for ranking participants by their level of sedentary and active behaviors.

Patient-physician race concordance and its relationship to perceived health outcomes.

OBJECTIVES: Race concordance occurs when the race of a patient matches the race of his/ her physician and discordance occurs when races do not match. Previous research has suggested an association between race concordance and measures of patient satisfaction and health outcome. In this study, we examined the relationship between race concordance and perceived quality of care, self-reported general health, and the SF-12 measures of physical and mental health in a community-based sample of 2001 adults. DESIGN: Telephone interviews were conducted with randomly selected households sampled from commercial lists of phone numbers. ANALYSIS: The association of concordance with the outcomes was analyzed separately for African American (n = 1,125) and White (n = 876) respondents using bivariate analysis and multiple linear regression. RESULTS: After controlling for age, sex, income, education, insurance status, and type of insurance, we found that race concordance was only associated with general health for White respondents (P < .006). Whites with insurance were more likely to be concordant than Whites without insurance and African Americans without insurance were more likely to be concordant than African Americans with insurance. CONCLUSIONS: Settings that employ a larger number of African American physicians in Nashville, Tennessee are places that people without insurance are more likely to seek health care. For health satisfaction and perceived health status, socioeconomic status and access to quality health care are likely more important than whether one's physician is of a similar or dissimilar race.

Trends in smoking among African-Americans: a description of Nashville's REACH 2010 initiative.

African Americans bear a disproportionate burden of tobacco related morbidity and mortality despite smoking less than their Caucasian counterparts. Nashville's REACH 2010 initiative developed community partnerships to promote awareness, education and participatory programs to prevent and decrease smoking among residents of the northern geographic area of Nashville, TN, a majority African American community. A social-ecological model provided the framework for interventions used during a 5 year period that included: (a) community level strategies to increase awareness and knowledge about the effects of smoking; (b) individual level strategies to enlist and train community members to become advocates, lead smoking cessation classes and encourage current smokers in quit attempts; and (c) strategies directed to changing policy through education and partnership building. Smoking prevalence among residents was examined from 2001 through 2005 based on data from the Nashville CDC REACH 2010 Risk Factor Survey and the Tennessee CDC Behavioral Risk Factor Survey. Tests for linear trends indicated a significant decreasing trend (P < .02) of daily smoking and smoking uptake (P < .03) in North Nashville. In contrast to our community an increasing trend was observed in quitting smoking (P < .01). No trends were significant for African Americans in Tennessee. This study suggests that consistent, multiple and multi-level strategies targeted to an African American community may impact smokers who are not ready to quit but willing to reduce their level of smoking. This study underscores the importance of developing and implementing community wide campaigns to address the needs of African Americans.

Development and validation of a religious health fatalism measure for the African-American faith community.

Health researchers struggle to understand barriers to improving health in the African-American community. The African-American church is one of the most promising venues for health promotion, disease prevention, and disparities reduction. Religious fatalism, the belief that health outcomes are inevitable and/or determined by God, may inhibit healthy behaviors for a subset of religious persons. This study reports the development and validation of the Religious Health Fatalism Questionnaire, a measurement tool for studying faith-related health beliefs in African-Americans. Participants included 276 members of seven predominantly African-American churches. Factor analysis indicated three dimensions: (1) Divine Provision; (2) Destined Plan; and (3) Helpless Inevitability. Evidence is presented for the reliability, convergent and predictive validity of the Religious Health Fatalism Questionnaire.

A conceptual model for using action inquiry technologies to address disparities in depression.

Disparities in depression care remain an important problem in the United States. Action inquiry technologies may assist individuals and communities in their attempts to reduce or eliminate these disparities--and the multiple factors contributing to them--through a recurring cycle of planning, action, evaluation, and new actions based on reflections about what occurred during previous actions. This article will briefly review different action inquiry methods--specifically, participatory action research (PAR) in communities and action research in physicians' practices and offices of continuing medical education (CME). The authors develop a conceptual model in which those involved in providing, receiving, and improving depression care can use action inquiry strategies that are coordinated using the domains-based outcomes assessment model. This conceptual model may help CME planners collaborate with others to address disparities in depression care.

Comparing diabetes prevalence between African Americans and Whites of similar socioeconomic status.

OBJECTIVES: We investigated whether racial disparities in the prevalence of type 2 diabetes exist beyond what may be attributable to differences in socioeconomic status (SES) and other modifiable risk factors. METHODS: We analyzed data from 34331 African American and 9491 White adults aged 40 to 79 years recruited into the ongoing Southern Community Cohort Study. Participants were enrolled at community health centers and had similar socioeconomic circumstances and risk factor profiles. We used logistic regression to estimate the association between race and prevalence of self-reported diabetes after taking into account age, SES, health insurance coverage, body mass index, physical activity, and hypertension. RESULTS: Multivariate analyses accounting for several diabetes risk factors did not provide strong support for higher diabetes prevalence rates among African Americans than among Whites (men: odds ratio [OR]=1.07; 95% confidence interval [CI]=0.95, 1.20); women: OR=1.13, 95% CI=1.04, 1.22). CONCLUSIONS: Our findings suggest that major differences in diabetes prevalence between African Americans and Whites may simply reflect differences in established risk factors for the disease, such as SES, that typically vary according to race.

Religious fatalism and its association with health behaviors and outcomes.

OBJECTIVE: To examine the association between religious fatalism and health care utilization, health behaviors, and chronic illness. METHODS: As part of Nashville's REACH 2010 project, residents (n=1273) participated in a random telephone survey that included health variables and the helpless inevitability subscale of the Religious Health Fatalism Questionnaire. RESULTS: Religious health fatalism was higher among African Americans and older participants. Some hypotheses about the association between fatalism and health outcomes were confirmed. CONCLUSION: Religious fatalism is only partially predictive of health behaviors and outcomes and may be a response to chronic illness rather than a contributor to unhealthy behaviors.

Disparities in smoking: data from the Nashville REACH 2010 project.

The Nashville REACH 2010 project is funded by the Centers for Disease Control and Prevention to reduce health disparities in diabetes and heart disease among African Americans in Nashville, Tenn. While Tennessee has the third highest smoking rate (26.1%) in the United States, there are few appropriate local data useful for planning and evaluating local antismoking interventions. Data gathered for Nashville REACH 2010 from 4 large random telephone surveys were pooled to produce a database (n = 15,076) to define the extent of the local smoking disparity and the subgroups with the highest and lowest prevalence of smoking. African American women were least likely to smoke (21.3%) followed by white women (24.9%), and then African American and white men (27.3% and 27.9%, respectively). Among African American subgroups, smoking was lowest in students (10.8%) and retirees (17.1%) and highest in unemployed men (45.9%). In a logistic regression, smoking was highest among single men, the lowest educational level, the unemployed, the lowest income groups, and those between 40 and 50 years of age.

Seat belt law enforcement and racial disparities in seat belt use.

BACKGROUND: Numerous reports have documented a lower prevalence of seat belt use among blacks in the United States, compared with whites. Limited data suggest that black-white disparities in states with primary seat belt laws (motorists can be stopped and cited solely for violating a seat belt law) are less marked than in states with secondary laws (motorists can be cited for violating a seat belt law only if stopped for another offense). METHODS: Data from the Fatality Analysis Reporting System were analyzed in 2005 to compare seat belt use among 11,574 blacks and 73,639 whites aged 16 or more years killed in crashes from 1999 to 2003 in 33 states with a primary or secondary adult seat belt law and annual reporting of race for 80% or more of decedents. After stratification of states by type of seat belt law, logistic regression was used to calculate odds ratios and 95% confidence intervals (CIs) for seat belt use among blacks, relative to whites, with adjustment for age, gender, seat position, urban/rural region, and income. RESULTS: Odds ratios and 95% CIs for seat belt use among blacks were 1.05 (0.97-1.13) and 0.89 (0.83-0.95), in primary- and secondary-law states, respectively. CONCLUSIONS: Black-white disparities in seat belt use were mitigated in states with primary seat belt laws. Only 24 states have primary laws. Enacting primary laws in other states might reduce or eliminate racial disparities in seat belt use.

An evaluation of the Nashville REACH 2010 community health screening strategy.

Community-based screening is 1 of 4 strategies selected by the Nashville REACH 2010 project for reducing disparities in heart disease and diabetes among African Americans in North Nashville, Tenn. We evaluated our screening efforts by asking 4 questions: (1) Are the screening participants representative of the target population? (2) How often were screening participants with possible undiagnosed hypertension, high cholesterol, and diabetes identified? (3) How often were screening participants with an elevated risk for developing hypertension, high cholesterol, and diabetes identified? and (4) How often did we identify screening participants with known hypertension, high cholesterol, and diabetes whose disease management was suboptimal? Results from 1757 persons screened were compared to telephone surveys from 16,199 Nashville residents. Those screened were younger and healthier than the target population. Rates of potentially undiagnosed cases among African Americans were 0.8% for diabetes, 17.4% for hypertension, and 32.7% for high cholesterol. High-risk individuals were identified 13.1% of the time for diabetes, 45.3% of the time for hypertension, and 21.3% of the time for total cholesterol. Rates of poorly controlled known disease were 23.5% for diabetes, 39.0% for hypertension, and 58.2% for total cholesterol. Although we reached a younger and healthier group than the community population, community-based screenings identified many people with potential health risks. We present a model of how to organize and implement successful community-based screening.