Patient Perspectives on Addressing Social Needs in Primary Care Using a Screening and Resource Referral Intervention.

BACKGROUND: Interest is growing in interventions to address social needs in clinical settings. However, little is known about patients' perceptions and experiences with these interventions. OBJECTIVE: To evaluate patients' experiences and patient-reported outcomes of a primary care-based intervention to help patients connect with community resources using trained volunteer advocates. DESIGN: Qualitative telephone interviews with patients who had worked with the volunteer advocates. Sample and recruitment targets were equally distributed between patients who had at least one reported success in meeting an identified need and those who had no reported needs met, based on the database used to document patient encounters. PARTICIPANTS: One hundred two patients. INTERVENTIONS: Patients at the study clinic were periodically screened for social needs. If needs were identified, they were referred to a trained volunteer advocate who further assessed their needs, provided them with resource referrals, and followed up with them on whether their need was met. APPROACH: Thematic analysis was used to code the data. KEY RESULTS: Interviewed patients appreciated the services offered, especially the follow-up. Patients' ability to access the resource to which they were referred was enhanced by assistance with filling out forms, calling community resources, and other types of navigation. Patients also reported that interacting with the advocates made them feel listened to and cared for, which they perceived as noteworthy in their lives. CONCLUSIONS: This patient-reported information provides key insights into a human-centered intervention in a clinical environment. Our findings highlight what works in clinical interventions addressing social needs and provide outcomes that are difficult to measure using existing quantitative metrics. Patients experienced the intervention as a therapeutic relationship/working alliance, a type of care that correlates with positive outcomes such as treatment adherence and quality of life. These insights will help design more patient-centered approaches to providing holistic patient care.

Engaging patients in primary care design: An evaluation of a novel approach to codesigning care.

OBJECTIVE: Recognition is growing that to create truly patient-centred care, health-care organizations need to partner with patients around care design. More research into the benefits of engaging patients and the most effective ways of partnering with them is needed. METHODS: This study assessed the process and impact of a collaborative effort to design a new clinic service that balanced the number of patient and clinical provider/staff codesigners involved and recruited patients to represent diverse perspectives. Data sources included interviews with participants, event observation and participant surveys. RESULTS: Our evaluation found that including patients as equal partners improved the design process by infusing a real-world, patient perspective. The pre-event orientation and interactive methods used in the event fostered positive collaboration, as well as personal growth for the patient codesigners. CONCLUSION: This study demonstrated the feasibility and benefits of including a roughly equal number of patients and clinical providers/staff in design events and ensuring that the patients represent diverse perspectives.

A Community-Wide Collaboration to Reduce Cardiovascular Disease Risk: The Hearts of Sonoma County Initiative.

PURPOSE AND OBJECTIVES: Collaboration across multiple sectors is needed to bring about health system transformation, but creating effective and sustainable collaboratives is challenging. We describe outcomes and lessons learned from the Hearts of Sonoma County (HSC) initiative, a successful multi-sector collaborative effort to reduce cardiovascular disease (CVD) risk in Sonoma County, California. INTERVENTION APPROACH: HSC works in both clinical systems and communities to reduce CVD risk. The initiative grew out of a longer-term county-wide collaborative effort known as Health Action. The clinical component involves activating primary care providers around management of CVD risk factors; community activities include community health workers conducting blood pressure screenings and a local heart disease prevention campaign. EVALUATION METHODS: The impact of the clinical improvement efforts was tracked using blood pressure data from the 4 health systems participating in HSC. Descriptive information on the community-engagement efforts was obtained from program records. Lessons learned in developing and maintaining the collaborative were gathered through document review and interviews with key informants. RESULTS: Favorable trends were seen in blood pressure control among patients with hypertension in the participating health systems: patients with controlled blood pressure increased from 58% in 2014 to 67% in 2016 (P < .001). Between 2017 and 2019, the community engagement effort conducted 99 outreach events, reaching 1,751 individuals, and conducted 1,729 blood pressure screenings, with 441 individuals referred to clinical providers for follow-up care. HSC scored highly on 6 essential elements of an effective coalition and achieved a degree of sustainability that has eluded many other collaboratives. IMPLICATIONS FOR PUBLIC HEALTH: Factors contributing to the success of HSC include 1) starting small and focused to build trust among participants and demonstrate value, 2) working within the framework of a larger effort, and 3) providing long-term, open-ended backbone support.

Improving oral health in migrant and underserved populations: evaluation of an interactive, community-based oral health education program in Washington state.

OBJECTIVES: Oral health is one of the greatest unmet health needs of migrant farmworkers and many migrant workers lack basic oral health knowledge. This paper presents evaluation results for an oral health education program designed to both increase knowledge concerning oral health practices and to gain a better understanding of the knowledge, attitudes and behaviors regarding oral health among migrant workers. METHODS: We used a pre-post uncontrolled design to assess the impact of the education program on participant knowledge about oral health practices. Changes in knowledge were assessed using a paper and pencil survey given to participants before the session began (pre) and at the end of the session (post). The pre-post survey was supplemented by qualitative information in the form of participant self-reported barriers and facilitators, and figure drawings illustrating their feelings about the state of their own oral health. RESULTS: There were 311 participants in 12 workshops held in 2017 throughout Washington State. There were statistically significant increases in knowledge for all of the pre/post survey questions. Questions with particularly large improvements included: the results of having a mouth infection, factors causing oral health problems, and whether children in low-income families experience more tooth decay. CONCLUSIONS: An interactive, lay-led oral health education program can be an effective way to increase oral health knowledge in migrant populations. Recommendations for similar programs include using interactive approaches to engage participants, being open to learning and changing your own thinking, and using lay leaders for the education sessions.

The Immunity Community: A Community Engagement Strategy for Reducing Vaccine Hesitancy.

Parental concerns about vaccine safety have grown in the United States and abroad, resulting in delayed or skipped immunizations (often called "vaccine hesitancy"). To address vaccine hesitancy in Washington State, a public-private partnership of health organizations implemented and evaluated a 3-year community intervention, called the "Immunity Community." The intervention mobilized parents who value immunization and provided them with tools to engage in positive dialogue about immunizations in their communities. The evaluation used qualitative and quantitative methods, including focus groups, interviews, and pre and post online surveys of parents, to assess perceptions about and reactions to the intervention, assess facilitators and barriers to success, and track outcomes including parental knowledge and attitudes. The program successfully engaged parent volunteers to be immunization advocates. Surveys of parents in the intervention communities showed statistically significant improvements in vaccine-related attitudes: The percentage concerned about other parents not vaccinating their children increased from 81.2% to 88.6%, and the percentage reporting themselves as "vaccine-hesitant" decreased from 22.6% to 14.0%. There were not statistically significant changes in parental behaviors. This study demonstrates the promise of using parent advocates as part of a community-based approach to reduce vaccine hesitancy.

Promoting Policy, Systems, and Environment Change to Prevent Chronic Disease: Lessons Learned From the King County Communities Putting Prevention to Work Initiative.

CONTEXT: Initiatives that convene community stakeholders to implement policy, systems, environment, and infrastructure (PSEI) change have become a standard approach for promoting community health. OBJECTIVE: To assess the PSEI changes brought about by the King County, Washington, Communities Putting Prevention to Work initiative and describe how initiative structures and processes contributed to making changes. DESIGN: The impact evaluation used a logic model design, linking PSEI changes to longer-term behavioral impacts in healthy eating active living and tobacco use and exposure. Qualitative methods, including stakeholder interviews and surveys, were used to identify initiative success factors. SETTING: Communities Putting Prevention to Work activities occurred throughout King County, with a focus on 7 low-income communities in South Seattle/King County. PARTICIPANTS: The focus communities had a combined population of 652 000, or 35% of the county total, with lower incomes and higher rates of physical inactivity, tobacco use, poor diet, and chronic disease. INTERVENTION: Twenty-four PSEI strategies were pursued by organizations in sectors including schools, local governments, and community organizations, supported by the public health department. There were 17 healthy eating active living strategies (eg, enhancements to school menus, city planning policies) and 7 tobacco strategies (eg, smoke-free policies in schools, housing, and hospitals). MAIN OUTCOME MEASURE: PSEI changes made and numbers of residents reached. RESULTS: Twenty-two of the 24 strategies achieved significant progress toward implementing PSEI changes. The most common success factor was a "dyad" consisting of a dedicated technical assistance provider-either an outside consultant or public health department staff-working closely with a champion from the participating organizations to bring about PSEI changes. CONCLUSIONS: An initiative structure that creates and supports external consultant/internal organizational champion dyads in key community sectors offers a promising approach that may be adopted by similar community health efforts in the future.

Using photovoice as a participatory evaluation tool in Kaiser Permanente's Community Health Initiative.

Photovoice is a community-based participatory research method that provides participants who traditionally have little voice in community policy decisions, with training in photography, ethics, critical dialogue, photo captioning, and policy advocacy. Photovoice has been used primarily as a needs assessment and advocacy tool and only rarely as a pre-/postintervention evaluation method. This article describes the use of Photovoice as a participatory evaluation method in the Community Health Initiative, a 6-year, multisite community-based obesity prevention initiative, sponsored by Kaiser Permanente. Fifty community participants (including six youth) from six Community Health Initiative communities used photos and captions to identify, from their perspective, the most significant accomplishments from the initiative at both baseline and follow-up. Accomplishments identified included increased access to fresh/healthy food in local neighborhoods; policy changes supporting a "healthy eating, active living" community; increased access to physical activity; changes to the built environment creating increased neighborhood walkability/safety; and leadership development.

A framework for disseminating evidence-based health promotion practices.

Wider adoption of evidence-based, health promotion practices depends on developing and testing effective dissemination approaches. To assist in developing these approaches, we created a practical framework drawn from the literature on dissemination and our experiences disseminating evidence-based practices. The main elements of our framework are 1) a close partnership between researchers and a disseminating organization that takes ownership of the dissemination process and 2) use of social marketing principles to work closely with potential user organizations. We present 2 examples illustrating the framework: EnhanceFitness, for physical activity among older adults, and American Cancer Society Workplace Solutions, for chronic disease prevention among workers. We also discuss 7 practical roles that researchers play in dissemination and related research: sorting through the evidence, conducting formative research, assessing readiness of user organizations, balancing fidelity and reinvention, monitoring and evaluating, influencing the outer context, and testing dissemination approaches.

The association between worksite social support, diet, physical activity and body mass index.

OBJECTIVE: Social support may be associated with improved diet and physical activity-determinants of overweight and obesity. Wellness programs increasingly target worksites. The aim was to evaluate the relationship between worksite social support and dietary behaviors, physical activity, and body mass index (BMI). METHOD: Baseline data were obtained on 2878 employees from 2005 to 2007 from 34 worksites through Promoting Activity and Changes in Eating, a group-randomized weight reduction intervention in Greater Seattle. Worksite social support, diet, physical activity, and BMI were assessed via self-reported questionnaire. Principal component analysis was applied to workgroup questions. To adjust for design effects, random effects models were employed. RESULTS: No associations were found with worksite social support and BMI, or with many obesogenic behaviors. However, individuals with higher worksite social support had 14.3% higher (95% CI: 5.6%-23.7%) mean physical activity score and 4% higher (95% CI: 1%-7%) mean fruit and vegetable intake compared to individuals with one-unit lower support. CONCLUSION: Our findings do not support a conclusive relationship between higher worksite social support and obesogenic behaviors, with the exception of physical activity and fruit and vegetable intake. Future studies are needed to confirm these relationships and evaluate how worksite social support impacts trial outcomes.

Correlation of Oral Health Education by Community Health Workers with Changes in Oral Health Practices in Migrant Populations in Washington State.

INTRODUCTION: An important question for oral health education is whether knowledge gained during lay-led workshops is retained and applied in daily practice. This study assessed the knowledge retention and changes in oral health practices several months after oral health education workshops were held for migrant farmworkers by Community Health Workers (CHWs). METHODS AND RESULTS: Follow-up surveys were conducted with 32 participants 1 to 43 months post participation (60% between 6 and 21 months). The results showed a high degree of retention, in such areas as general oral health knowledge, and brushing/flossing frequency and technique among this sample. There was no relationship between length of time since the educational workshop and knowledge retained or behaviors changed. CONCLUSIONS AND RECOMMENDATIONS: An interactive, lay-led oral health education program run by CHWs can be an effective way to deliver sustained improvements in oral health knowledge and changes in oral health practice in migrant populations.

Counting the Unsung by Promoting Participation in the 2020 US Census: A Survey of Migrant Workers in Washington State.

INTRODUCTION: Participation in the United States Census is critical for determining congressional representation and federal funding, but in every census there are groups systematically undercounted due to socioeconomic and demographic factors. Migrants and refugees are a group particularly threatened by being undercounted, including Hispanic migrant workers living in more rural areas. METHODS AND RESULTS: To gather information to promote migrant participation in the census, the Community Health Worker Coalition for Migrants and Refugees in Washington state conducted a systematic survey of 71 migrant workers in seven urban and suburban Washington communities. The results showed that while most participants had heard of the census, basic knowledge about the census was limited and people wanted more information. CONCLUSIONS AND RECOMMENDATIONS: A strong, coordinated outreach approach should be carried out to educate people in migrant communities about the census. This may involve one-on-one structured conversations, radio telenovelas, and community conversations organized by the trusted leaders.

A Multicomponent Health Education Campaign Led by Community Health Workers to Increase Influenza Vaccination among Migrants and Refugees.

OBJECTIVES: To evaluate the impact of a Community Health Worker (CHW)-led influenza campaign on knowledge and attitudes about vaccination in Latinx migrant and refugee populations. METHODS: Twelve online workshops were conducted with 183 participants and 24 CHWs between January 12 and May 12, 2021. Participants were Latinx families living in underserved communities throughout Washington state. The initiative also included radio, animated videos, advertisements, social media, and educational materials. RESULTS: Analysis of pre and post workshop surveys from 155 participants showed statistically significant improvements in all questions about the definition of influenza, symptoms, and risks: and in 7 of 9 questions about treatments and vaccines. Analysis of 2 open-ended questions showed increases in words key to understanding influenza, such as "virus," "illness," "death," and "contagious." There were significant increases in rates of participants identifying vaccination and antibiotics as cures for influenza. CONCLUSIONS: CHW-led workshops can be an effective way to increase knowledge about influenza and influenza vaccine. Future curriculum should emphasize the difference between viruses and bacteria, and the use of vaccination for prevention as opposed to treatment for illness.

Release from prison--a high risk of death for former inmates.

BACKGROUND: The U.S. population of former prison inmates is large and growing. The period immediately after release may be challenging for former inmates and may involve substantial health risks. We studied the risk of death among former inmates soon after their release from Washington State prisons. METHODS: We conducted a retrospective cohort study of all inmates released from the Washington State Department of Corrections from July 1999 through December 2003. Prison records were linked to the National Death Index. Data for comparison with Washington State residents were obtained from the Wide-ranging OnLine Data for Epidemiologic Research system of the Centers for Disease Control and Prevention. Mortality rates among former inmates were compared with those among other state residents with the use of indirect standardization and adjustment for age, sex, and race. RESULTS: Of 30,237 released inmates, 443 died during a mean follow-up period of 1.9 years. The overall mortality rate was 777 deaths per 100,000 person-years. The adjusted risk of death among former inmates was 3.5 times that among other state residents (95% confidence interval [CI], 3.2 to 3.8). During the first 2 weeks after release, the risk of death among former inmates was 12.7 (95% CI, 9.2 to 17.4) times that among other state residents, with a markedly elevated relative risk of death from drug overdose (129; 95% CI, 89 to 186). The leading causes of death among former inmates were drug overdose, cardiovascular disease, homicide, and suicide. CONCLUSIONS: Former prison inmates were at high risk for death after release from prison, particularly during the first 2 weeks. Interventions are necessary to reduce the risk of death after release from prison.

The Kaiser Permanente Community Health Initiative: overview and evaluation design.

We provide an overview of the Kaiser Permanente Community Health Initiative--created in 2003 to promote obesity-prevention policy and environmental change in communities served by Kaiser Permanente-and describe the design for evaluating the initiative. The Initiative focuses on 3 ethnically diverse northern California communities that range in size from 37,000 to 52,000 residents. The evaluation assesses impact by measuring intermediate outcomes and conducting pre- and posttracking of population-level measures of physical activity, nutrition, and overweight.

Approaches to measuring the extent and impact of environmental change in three California community-level obesity prevention initiatives.

Despite growing support among public health researchers and practitioners for environmental approaches to obesity prevention, there is a lack of empirical evidence from intervention studies showing a favorable impact of either increased healthy food availability on healthy eating or changes in the built environment on physical activity. It is therefore critical that we carefully evaluate initiatives targeting the community environment to expand the evidence base for environmental interventions. We describe the approaches used to measure the extent and impact of environmental change in 3 community-level obesity-prevention initiatives in California. We focus on measuring changes in the community environment and assessing the impact of those changes on residents most directly exposed to the interventions.

Promoting sustainable community change in support of older adult physical activity: evaluation findings from the Southeast Seattle Senior Physical Activity Network (SESPAN).

Researchers have identified as effective and worthy of broader dissemination a variety of intervention strategies to promote physical activity among older adults. This paper reports results of a community-organizing approach to disseminating evidence-based interventions in a sustainable way: The Southeast Seattle Senior Physical Activity Network (SESPAN). SESPAN was implemented in Southeast Seattle, a group of multicultural neighborhoods extending 8 miles southeast of downtown Seattle, with a population of 56,469 in 2000, with 12% (7,041) aged 65 and older. The SESPAN organizing strategy involved networking to: (1) make connections between two or more community organizations to create new senior physical activity programs; and (2) build coalitions of community groups and organizations to assist in making larger scale environmental and policy changes to increase senior physical activity. The SESPAN evaluation used an uncontrolled prospective design focusing on sustainable community changes, including new or modified programs, policies, and practices. Networking among organizations led to the creation of 16 ongoing exercise classes and walking groups, serving approximately 200 older adults in previously underserved Southeast Seattle communities. In addition, the project's health coalition is sustaining current activities and generating new programs and environmental changes. The success of the SESPAN organizing model depended on identifying and involving champions in partner organizations who provided support and resources for implementing programs.

Health care costs and participation in a community-based health promotion program for older adults.

INTRODUCTION: EnhanceWellness (EW) is a community-based health promotion program that helps prevent disabilities and improves health and functioning in older adults. A previous randomized controlled trial demonstrated a decrease in inpatient use for EW participants but did not evaluate health care costs. We assessed the effect of EW participation on health care costs. METHODS: We performed a retrospective cohort study in King County, Washington. Enrollees in Group Health Cooperative (GHC), a mixed-model health maintenance organization, who were aged 65 years or older and who participated in EW from 1998 through 2005 were matched 1:3 by age and sex to GHC enrollees who did not participate in EW. We matched 218 EW participants by age and sex to 654 nonparticipants. Participants were evaluated for 1 year after the date they began the program. The primary outcome was total health care costs; secondary outcomes were inpatient costs, primary care costs, percentage of hospitalizations, and number of hospital days. We compared postintervention outcomes between EW participants and nonparticipants by using linear regression. Results were adjusted for prior year costs (or health care use), comorbidity, and preventive health care-seeking behaviors. RESULTS: Mean age of participants and nonparticipants was 79 years, and 72% of participants and nonparticipants were female. Adjusted total costs in the year following the index date were $582 lower among EW participants than nonparticipants, but this difference was not significant. CONCLUSION: Although EW participation demonstrated health benefits, participation does not appear to result in significant health care cost savings among people receiving health care through a health maintenance organization.

A community-organizing approach to promoting physical activity in older adults: the southeast senior physical activity network.

This article describes a community organizing approach to promoting physical activity among underserved older adults in southeast Seattle: the Southeast Senior Physical Activity Network (SESPAN). The organizing strategy involves networking with a variety of community-based organizations, with two broad objectives: (a) program objective-to make connections between two (or more) community-based organizations to create senior physical activity programs where none existed before; and (b) coalition objective-to build a broader network or coalition of groups and organizations to assist in making larger scale environmental and policy changes. Networking among organizations led to the creation of a number of potentially sustainable walking and exercise programs that are reaching previously underserved communities within Southeast Seattle. In addition, a major community event led to the establishment of a health coalition that has the potential to continue to generate new broad-based programs and larger scale environmental changes.

Promoting policy and environmental change using photovoice in the Kaiser Permanente Community Health Initiative.

Creative ways must be found to engage both community residents and political leaders around policy and environmental solutions to public health issues. Photovoice is a community-based, participatory approach to documentary photography that provides people with training on photography, ethics, critical discussion, and policy advocacy. Photovoice projects have been implemented across the nation as part of Kaiser Permanente's Community Health Initiative-a community-based obesity prevention effort. This article focuses on the first Photovoice project implemented in three communities in Colorado. Photovoice themes related to healthy eating and active living include a lack of access to healthy food choices in stores and schools, unsafe street crossings and sidewalks, and the need to redevelop certain areas to encourage safe recreation. The involvement of policy leaders in the project combined with several dissemination activities has contributed to healthier food offerings in schools and neighborhoods and city planning efforts that emphasize walkability and access to healthy food, and park revitalization.

Using the County Health Rankings Framework to Create National Percentile Scores for Health Outcomes and Health Factors.

INTRODUCTION: As a means of conceptualizing population health, the County Health Rankings & Roadmaps program developed a methodology to rank counties within each state on Health Outcomes and Health Factors. We built on this framework by introducing an additional application that utilized national percentile scores and population size weighting to compare counties on a national, rather than a state, level. METHODS: We created national percentile scores for 3078 US counties and used population size weighting in our calculations so that values for counties with larger populations would be weighted more heavily than values for counties with smaller populations. RESULTS: We demonstrated how this application can be used to 1) compare counties nationally, 2) examine clustering and variability among counties, and 3) compare the health of states and regions. To underscore its utility, we included an example application by Kaiser Permanente. As a form of method validation, the results of this application are in line with other ranking systems (eg, US News and World Report and United Health Foundation; ρ = 0.39 to 0.91, p < 0.001). DISCUSSION: This application can be used by communities and organizations that may be interested in comparing the health of counties, service areas, and regions in which they operate. We included additional considerations and highlighted some limitations for those interested in utilizing this application. CONCLUSION: By comparing counties nationally and utilizing population size weighting, community partners can focus on areas that may be of greatest need in moving toward a national Culture of Health.