Group-based trajectory analysis identifies varying diabetes-related cost trajectories among type 2 diabetes patients in Texas: an empirical study using commercial insurance.

BACKGROUND: The trend of Type 2 diabetes-related costs over 4 years could be classified into different groups. Patient demographics, clinical factors (e.g., A1C, short- and long-term complications), and rurality could be associated with different trends of cost. Study objectives are to: (1) understand the trajectories of cost in different groups; (2) investigate the relationship between cost and key factors in each cost trajectory group; and (3) assess significant factors associated with different cost trajectories. METHODS: Commercial claims data in Texas from 2016 to 2019 were provided by a large commercial insurer and were analyzed using group-based trajectory analysis, longitudinal analysis of cost, and logistic regression analyses of different trends of cost. RESULTS: Five groups of distinct trends of Type 2 diabetes-related cost were identified. Close to 20% of patients had an increasing cost trend over the 4 years. High A1C values, diabetes complications, and other comorbidities were significantly associated with higher Type 2 diabetes costs and higher chances of increasing trend over time. Rurality was significantly associated with higher chances of increasing trend over time. CONCLUSIONS: Group-based trajectory analysis revealed distinct patient groups with increased cost and stable cost at low, medium, and high levels in the 4-year period. The significant associations found between the trend of cost and A1C, complications, and rurality have important policy and program implications for potentially improving health outcomes and constraining healthcare costs.

Discrepancies between Perceived and Physiological Fall Risks and Repeated Falls among Community-Dwelling Medicare Beneficiaries Aged 65 Years and Older.

OBJECTIVES: This study examined the associations of discrepancies between perceived and physiological fall risks with repeated falls. METHODS: We analyzed the 2016 Medicare Current Beneficiary Survey of 2,487 Medicare beneficiaries aged ≥ 65 years with ≥ 1 fall. The outcome variable was repeated falls (≥ 2 falls), the key independent variable was a categorical variable of discrepancies between perceived (fear of falling) and physiological fall risks (physiological limitations), assessed using multivariate logistic regression. RESULTS: Among Medicare beneficiaries with ≥ 1 fall, 25.1% had low fear of falling but high physiological fall risk (Low Fear-High Physiological), 9.4% had high fear of falling but low physiological fall risk (High Fear-Low Physiological), 23.5% had low fear of falling and low physiological fall risks (Low Fear-Low Physiological), and 42.0% had high fear of falling and high physiological fall risks (High Fear-High Physiological). Having High Fear-High Physiological was associated with repeated falls (OR = 2.14; p < .001) compared to Low Fear-Low Physiological. Having Low Fear-High Physiological and High Fear-LowPhysiological were not associated with repeated falls. CONCLUSIONS: Given that High Fear-High Physiological was associated with repeated falls and that many at-risk Medicare beneficiaries had High Fear-High Physiological, prevention efforts may consider targeting those most at-risk including Medicare beneficiaries with High Fear-High Physiological. CLINICAL IMPLICATIONS: Assessing both perceived and physiological fall risks is clinically relevant, given it may inform targeted interventions for different at-risk Medicare beneficiaries among clinicians and other stakeholders.

A Multi-Level Analyses of Charges and Cost of Fall-Related Hospitalizations Among Older Adults: Individual, Hospital, and Geospatial Variation.

The growing population of older adults has attracted concern from policymakers due in part to the fact that they are at higher risk of costly and potentially injurious falls. Responding to this concern, this study investigated fall-related hospitalizations among those aged 65 and older. Hospitalizations rose from 49,299 to 58,931, with charges and costs (estimated based on charges) increasing from $2.5 billion to $3.6 billion and under $900 million to over $1.1 billion, respectively. The intraclass correlation coefficients from linear mixed-effect models (with charges and costs serving as dependent variables) indicated differences in hospitals accounted for nearly half or more of medical cost variation among older adults suffering a fall-related hospitalization. Nonmetropolitan residence, being aged 65-69 (versus older), and higher risk-of-mortality on admission indicated higher costs. Identifying trends of fall-related hospitalizations over time allows for key stakeholders to not only track the burden of falls among older adults but to also use this information to attract funding for fall prevention strategies from policy makers at various levels (e.g., locally, at the state). Further, identifying characteristics of individuals (e.g., age, race, sex) and places (e.g., rural areas) that carry a higher relative cost can serve to inform the targeted allocation of finite resources including local, state, or federal funding, but also existing evidence-based practices such as community and clinical interventions.

The role of improved social support for healthy eating in a lifestyle intervention: Texercise Select.

OBJECTIVE: We examined the measurement and mediating role of social support in dietary intake among participants in Texercise Select, an intervention for improving lifestyle behaviours. DESIGN: Quasi-experimental study. Participants reported their dietary intake, level of social support measured by the new Social Support for Healthy Eating scale, sociodemographics and disease profile. We conducted exploratory factor analysis for scale evaluation and structural equation modelling for mediation analysis to test if changes in dietary-specific social support mediate the relationship between the intervention and changes in dietary intake. SETTING: Texas. PARTICIPANTS: Community-dwelling middle-aged and older adults completed a self-reported survey at baseline and 3-month follow-up (intervention group n 211, comparison group n 175). RESULTS: The majority of the sample was aged ≥70 years (mean 74·30, sd 8·54), female (82·1 %) and had at least two chronic conditions (63·5 %). The acceptable levels of reliability and validity of the dietary-specific social support scale were confirmed. Compared with the comparison group, the intervention group reported improved intake of fruit/vegetables and water, and improved dietary-specific social support. Improved dietary-specific social support mediated the association between intervention and change in fruit/vegetable intake, controlling for sociodemographics, number of chronic conditions and geographic residence. About 12 % of intervention effect was mediated by social support. CONCLUSIONS: The current study confirms positive intervention effects on healthy eating, and highlights social support relating to dietary behaviours that may be helpful for healthy eating. Future research should investigate additional social support for developing healthy eating behavioural skills.

Effectiveness and economic impact of a diabetes education program among adults with type 2 diabetes in South Texas.

BACKGROUND: The long-term growth and sustained high prevalence of obesity in the US is likely to increase the burden of Type 2 diabetes. Hispanic individuals are particularly burdened by a larger share of diabetes than non-Hispanic White individuals. Given the existing health disparities facing this population, we aimed to examine the effectiveness and potential cost savings of the Diabetes Education Program (DEP) offered as part of Healthy South Texas, a state-legislated initiative to reduce health disparities in 27 counties in South Texas with a high proportion of Hispanic adults. METHODS: DEP is an 8-h interactive workshop taught in English and Spanish. After the workshop, participants receive quarterly biometric screenings and continuing education with a health educator for one year. Data were analyzed from 3859 DEP participants with Type 2 diabetes living in South Texas at five time points (baseline, 3-months, 6-months, 9-months, 12-months). The primary outcome variable of interest for study analyses was A1c. A series of independent sample t-tests and linear mixed-model regression analyses were used to identify changes over time. Two methods were then applied to estimate healthcare costs savings associated with A1c reductions among participants. RESULTS: The majority of participants were ages 45-64 years (58%), female (60%), Hispanic (66%), and had a high school education or less (75%). At baseline, the average hemoglobin A1c was 8.57%. The most substantial reductions in hemoglobin A1c were identified from baseline to 3-month follow-up (P < 0.001); however, the reduction in A1c remained significant from baseline to 12-month follow-up (P < 0.001). The healthcare cost savings associated with improved A1c for the program was estimated to be between $5.3 to $5.6 million over a two to three year period. CONCLUSION: Findings support the effectiveness of DEP with ongoing follow-up for sustained diabetes risk management. While such interventions foster clinical-community collaboration and can improve patient adherence to recommended lifestyle behaviors, opportunities exist to complement DEP with other resources and services to enhance program benefits. Policy makers and other key stakeholders can assess the lessons learned in this effort to tailor and expand similar initiatives to potentially at-risk populations. TRIAL REGISTRATION: This community-based intervention is not considered a trial by ICMJE definitions, and has not be registered as such.

Health-related consequences of the type and utilization rates of electronic devices by college students.

BACKGROUND: College students are leading an evolution of device use both in the type of device and the frequency of use. They have transitioned from desktop stations to laptops, tablets, and especially smartphones and use them throughout the day and into the night. METHODS: Using a 35-min online survey, we sought to understand how technology daily usage patterns, device types, and postures affect pain and discomfort to understand how knowledge of that pain might help students avoid it. Data were analyzed from 515 students (69.5% male) who completed an internet-delivered survey (81.3% response rate). RESULTS: Participants ranked smartphones as their most frequently used technology (64.0%), followed by laptops and tablets (both 53.2%), and desktop computers (46.4%). Time spent using smartphones averaged over 4.4 h per day. When using their devices, students were more likely to adopt non-traditional workplace postures as they used these devices primarily on the couch or at a chair with no desk. CONCLUSION: Recent trends in wireless academic access points along with the portability of small handheld devices, have made smartphones the most common link to educational materials despite having the least favorable control and display scenario from an ergonomic perspective. Further, the potential impact of transitions in work environments due to COVID-19 may further exacerbate ergonomic issues among millions highlighting the need for such work to be carried out.

Violence against healthcare workers and other serious responses to medical disputes in China: surveys of patients at 12 public hospitals.

BACKGROUND: Workplace violence against healthcare workers is a global issue that is on the rise, with Chinese healthcare workers facing growing challenges with hospital violence. Attacks on medical staff have increased in recent years with no clear resolution. Prior research focused on policies to improve the doctor-patient relationship and better protect clinicians, but few studies addressed the patient perspective. This paper examines patients' choices when facing a medical dispute and identifies groups who are more likely to respond to conflict with violence or other serious actions. METHODS: Patient survey responses were collected in 12 leading public hospitals in five Chinese provinces with 5556 participants. The survey asked sociodemographic information, patients' attitudes (e.g., general optimism, trust in their physicians, perceived healthcare quality), and their primary response to a medical dispute. From least to most severe, the options range from "complaining within the family" to "violence." We used t-tests and Chi-square tests to explore the relationships between reactions and patient characteristics. We also performed multivariable logistic regressions to determine the impact of sociodemographics and provider trust on the seriousness of responses. RESULTS: The primary response of a third of respondents was complaining to hospital or health department officials (32.5%). Seeking legal help (26.3%) and direct negotiation with doctors (19.6%) were other frequent responses. More serious responses included 83 stating violence (1.5%), 9.7% expressing a desire to expose the issue to the news media, and 7.4% resorting to seeking third-party assistance. Patients who were more likely to report "violence" were male (OR = 1.81, p < .05), high-income earners (OR = 3.71, p < .05), or reported lower life satisfaction (OR = 1.40, p < .05). Higher trust scores were associated with a lower likelihood of a serious response, including violence (OR = 0.80, p < .01). CONCLUSION: Most respondents reported mild reactions when facing a medical dispute. Among those who reported the intent of serious reactions, some sociodemographic characteristics and the trust of physicians could be predictive. To prevent future hospital violence, this work helps identify the characteristics of patients who are more likely to seek severe approaches to medical dispute resolution, including resorting to violence. From these results, hospitals will be better able to target specific groups for interventions that build patient-provider trust and improve general patient satisfaction.

Factors Associated With Avoiding Health Care Among Community-Dwelling Medicare Beneficiaries With Type 2 Diabetes.

INTRODUCTION: Health care avoidance by Medicare beneficiaries with chronic conditions such as type 2 diabetes can result in adverse health and economic outcomes. The objective of this study was to describe factors associated with choices to avoid health care among Medicare beneficiaries with type 2 diabetes. METHODS: We used a survey-weighted logistic model and the nationally representative 2016 Medicare Current Beneficiary Survey to analyze data on 1,782 Medicare beneficiaries aged ≥65 with type 2 diabetes, to examine associations between Medicare beneficiaries' decisions to avoid health care and multiple factors (eg, dissatisfaction with information given by providers, health problems that should have been discussed with providers but were not, worry about health more than other people their age). RESULTS: Of our study sample, 26.1% reported they avoid health care. Five factors were associated with avoiding health care: delaying care (vs not) because of costs (adjusted odds ratio [aOR] = 2.06; P = .005); having health problems that should have been discussed with providers but were not (vs having discussions) (aOR = 1.50; P = .04); worrying (vs not) about health more than other people their age (aOR = 2.13; P < .001); self-reporting "other" minority race (vs non-Hispanic White) (aOR = 2.01; P = .006); and education levels. Participants with less than a high school diploma (aOR = 1.95; P = .001) and participants with a high school diploma only (aOR = 1.49; P = .049) were more likely than participants with an education beyond high school to report avoiding health care. CONCLUSION: Approximately 1 in 4 Medicare beneficiaries with type 2 diabetes avoid health care. We found inequities in care-seeking behavior by race/ethnicity and education level. Health care perceptions and lack of appropriate discussion of health care concerns with health care providers are also associated with this behavior. Clinical interventions (eg, improved patient-provider communication) and educational outreach are needed to decrease the numbers of Medicare beneficiaries who avoid health care.

The Association of Social Isolation With the Risk of Stroke Among Middle-Aged and Older Adults in China.

Given that there is limited research examining the specific role social isolation plays in stroke risk, we aimed to estimate the controlled direct effect of social isolation on stroke risk in China. A nationally representative sample (n = 12,662) of persons aged 45 years or more at baseline (2011), with corresponding follow-ups in 2013 and 2015, was taken from the China Health and Retirement Longitudinal Study. Stroke was assessed through a self- or proxy-reported physician's diagnosis. Social isolation was measured by incorporating marital status, frequency of contact with friends, family, and children, and participation in social activities. A marginal structural model with stabilized inverse probability weights was applied to examine the controlled direct effect of social isolation on stroke risk. Overall, 245 persons had a stroke within the 4-year timeline under study. The total effect model indicated that persons experiencing social isolation had a 64% increased risk of stroke (odds ratio (OR) = 1.64, 95% confidence interval (CI): 1.26, 2.13). Results from the marginal structural model also indicated that socially isolated persons had an increased risk of stroke (OR = 2.39, 95% CI: 1.49, 3.82) after adjustment for depression. Interventions to reduce social isolation may be particularly beneficial in preventing the occurrence of stroke among middle-aged and older adults in China.

Geographic disparities associated with travel to medical care and attendance in programs to prevent/manage chronic illness among middle-aged and older adults in Texas.

INTRODUCTION: Accessing care is challenging for adults with chronic conditions. The challenge may be intensified for individuals needing to travel long distances to receive medical care. Transportation difficulties are associated with poor medication adherence and delayed or missed care. This study investigated the relationship between those traveling greater distances for medical care and their utilization of programs to prevent and/or manage their health problems. It was hypothesized that those traveling longer distances for medical care attended greater chronic disease management programs. METHODS: Thirty six thousand households in nine counties of central Texas received an invitation letter to participate in a mailed health assessment survey in English or Spanish. A total of 5230 participants agreed to participate and returned the fully completed survey. To investigate distance traveled for medical services and participation in a chronic disease management program, the analyses were limited to 2108 adults aged ≥51 years with one or more chronic conditions who visited a healthcare professional at least once in the previous year. Other variables of interest included residential rurality, health status, and personal characteristics. The data were first analyzed using descriptive and bivariate analyses. Then, an ordinal logistic regression model was fitted to identify factors associated with longer distances traveled to medical services. Additionally, a binary logistic regression model was fitted to identify factors associated with attending a chronic disease self-management program. RESULTS: Among 2108 adults, rural participants (p<0.001), those with more chronic conditions (p<0.001), and those attending a chronic disease program (p=0.037) reported traveling further distances to medical services. Participants with limited activity (p<0.001), those from urban counties (p=0.017), and those who traveled further (p=0.030) were more likely to attend a chronic disease program. CONCLUSION: While further distances to healthcare providers was found to be a protective factor based on the utilization of community-based resources, rural residents were less likely to attend a program to better manage their chronic conditions, potentially choosing to use long distance travel to address urgent medical needs rather than focusing on prevention and management of their conditions. Important policy and programmatic efforts are needed to increase reach of chronic disease self-management programs and other community services and resources in rural areas and to reduce rural inequities.

Association between fruit and vegetable intake and the risk of hypertension among Chinese adults: a longitudinal study.

PURPOSE: Fruit and vegetable intake has been inversely associated with the risk of hypertension; however, there is inconsistent evidence on the long-term association. Given this gap in the literature, it is necessary to identify evidence from large prospective studies, especially in China, where insufficient evidence exists. Thus, we examined the association of fruit and vegetable intake with incident hypertension in Chinese adults. METHODS: We conducted analyses among 5659 Chinese adults aged 18-64 years, free of cardiovascular disease, cancer, and hypertension in the 2006 wave of the China Health and Nutrition Survey. Fruit and vegetable intake was assessed using consecutive 24-h recalls. Incident hypertension was identified from the 2011 wave of the survey. RESULTS: A total of 866 participants developed incident hypertension. The relative risks (RRs) and 95% confidence intervals (CIs) of hypertension were 0.74 (0.55-0.99), 0.65 (0.48-0.88), 0.68 (0.50-0.92), and 0.73 (0.53-0.99) comparing each quintile group of fruit and vegetable intake with the lowest quintile group. These associations attenuated for the change of intake but remained significant for the fourth quintile, of which the RR (95% CI) was 0.65 (0.47-0.89). The magnitude of association was stronger among those who were younger, female, overweight and had prehypertension. When examined separately, fruit intake was more strongly and significantly associated with lowering BP than vegetable intake. Adding body mass index to the models attenuated all associations. CONCLUSIONS: Greater long-term intake and increased intake of fruit and vegetables may reduce the risk of developing hypertension in Chinese adults.

Chronic disease self-management education courses: utilization by low-income, middle-aged participants.

BACKGROUND: Individuals living in lower-income areas face an increased prevalence of chronic disease and, oftentimes, greater barriers to optimal self-management. Disparities in disease management are seen across the lifespan, but are particularly notable among middle-aged adults. Although evidence-based Chronic Disease Self-management Education courses are available to enhance self-management among members of this at-risk population, little information is available to determine the extent to which these courses are reaching those at greatest risk. The purpose of this study is to compare the extent to which middle-aged adults from lower- and higher-income areas have engaged in CDSME courses, and to identify the sociodemographic characteristics of lower-income, middle aged participants. METHODS: The results of this study were produced through analysis of secondary data collected during the Communities Putting Prevention to Work: Chronic Disease Self-Management Program initiative. During this initiative, data was collected from 100,000 CDSME participants across 45 states within the United States, the District of Columbia, and Puerto Rico. RESULTS: Of the entire sample included in this analysis (19,365 participants), 55 people lived in the most impoverished counties. While these 55 participants represented just 0.3% of the total study sample, researchers found this group completed courses more frequently than participants from less impoverished counties once enrolled. CONCLUSION: These results signal a need to enhance participation of middle-aged adults from lower-income areas in CDSME courses. The results also provide evidence that can be used to inform future program delivery choices, including decisions regarding recruitment materials, program leaders, and program delivery sites, to better engage this population.

Accessing physical activity among young adults attending a university: the role of sex, race/ethnicity, technology use, and sleep.

BACKGROUND: Identifying factors associated with recommended physical activity (PA) levels are critical in efforts to combat the obesity epidemic and related comorbidities. METHODS: We conducted cross-sectional analyses of college students (n = 490) enrolled in a large southern state university in October of 2014. Our aim was to identify sociodemographic characteristics, technology use, and sleep patterns among college students and their independent relationship to recommended PA. An online survey was sent to all enrolled students. Logistic regression predicted achieving recommended ≥150 min per week of moderate-vigorous PA (MVPA) versus not (≤149 min MVPA). RESULTS: Approximately 69% of study participants were males, 18% were Hispanic, and more than half (60%) were within the normal body mass index (12% were obese). The average age of students was 21 years. On a daily average, individuals used smartphones most often (nearly 4.4 h), followed by laptops at 4.0 h, desktops at 1.2 h, and tablets at 0.6 h. The mean number of hours individuals reported sleeping was 6.7. Sociodemographic factors associated with reporting ≥150 min of MVPA included being male (OR = 4.0, 95% CI 2.2-7.1) versus female, being non-Hispanic White (OR = 1.8, CI 1.1-3.2) versus being a member of minority race group. Behavioral factors associated with reporting ≥150 min of MVPA included technology use (being moderate-heavy (OR = 2.3, CI 1.1-4.8) or heavy (OR = 3.4, CI 1.6-7.5) users of technology), and receiving low-moderate (OR = 1.9, 1.01-3.7) levels of sleep versus the lowest level of sleep. CONCLUSIONS: In the current study, minority status and being female were the strongest sociodemographic factors associated with inadequate PA levels, while high technology use (primarily driven by smartphone use) were associated with recommended PA levels. Identifying factors associated with being physically active will allow for targeted interventions to improve the health of young adults.

Meausures of organizational characteristics associated with adoption and/or implementation of innovations: A systematic review.

BACKGROUND: This paper identifies and describes measures of constructs relevant to the adoption or implementation of innovations (i.e., new policies, programs or practices) at the organizational-level. This work is intended to advance the field of dissemination and implementation research by aiding scientists in the identification of existing measures and highlighting methodological issues that require additional attention. METHODS: We searched for published studies (1973-2013) in 11 bibliographic databases for quantitative, empirical studies that presented outcome data related to adoption and/or implementation of an innovation. Included studies had to assess latent constructs related to the "inner setting" of the organization, as defined by the Consolidated Framework for Implementation Research. RESULTS: Of the 76 studies included, most (86%) were cross sectional and nearly half (49%) were conducted in health care settings. Nearly half (46%) involved implementation of evidence-based or "best practice" strategies; roughly a quarter (26%) examined use of new technologies. Primary outcomes most often assessed were innovation implementation (57%) and adoption (34%); while 4% of included studies assessed both outcomes. There was wide variability in conceptual and operational definitions of organizational constructs. The two most frequently assessed constructs included "organizational climate" and "readiness for implementation." More than half (55%) of the studies did not articulate an organizational theory or conceptual framework guiding the inquiry; about a third (34%) referenced Diffusion of Innovations theory. Overall, only 46% of articles reported psychometric properties of measures assessing latent organizational characteristics. Of these, 94% (33/35) described reliability and 71% (25/35) reported on validity. CONCLUSIONS: The lack of clarity associated with construct definitions, inconsistent use of theory, absence of standardized reporting criteria for implementation research, and the fact that few measures have demonstrated reliability or validity were among the limitations highlighted in our review. Given these findings, we recommend that increased attention be devoted toward the development or refinement of measures using common psychometric standards. In addition, there is a need for measure development and testing across diverse settings, among diverse population samples, and for a variety of types of innovations.

Social and environmental predictors of walking among older adults.

BACKGROUND: Regular physical activity (PA) is a major factor in maintaining health in aging populations. This study examines the influences of sociodemographic, health, and environmental characteristics on older adults' walking behaviors, and the role physicians can play in promoting physical activity. METHODS: Online and paper surveys (n = 272) were distributed to community-dwelling older (age ≥ 60) adults from a large integrated healthcare system in two counties in Central Texas. Descriptive statistics were utilized to characterize participant's walking behaviors and places. Multivariate logistic regression was employed to predict being: 1) a frequent walker (i.e., walking at least three times a week); and 2) meeting the Centers for Disease Control and Prevention (CDC) PA recommendation through walking (i.e., walking ≥150 min per week), while considering sociodemographic, health, and environmental factors. RESULTS: Individuals had a median age of 69 years, were of both genders (50.37 % female), and were primarily non-Hispanic White (84.87 %). While the majority (59.55 %) walked at least three times a week, only 27.86 % walked ≥150 min a week. Factors associated with a lower likelihood of being frequent walkers included experiencing poor mental health in the past month (OR = 0.345, 95 % CI = 0.185-0.645) and residing in areas with low or moderate (versus high) perceived neighborhood cohesion (OR = 0.471, 95 % CI = 0.228-0.974), while those in Census Tracts reflecting populations with a lower median age were more likely to report frequent walking behavior (OR = 1.799, 95 % CI = 1.034-3.131). Factors associated with a lower likelihood of meeting the CDC PA recommendation included being 60-69 years (versus 70 years or older) (OR = 0.538, 95 % CI = 0.290-0.997), experiencing poor mental health in the past month (OR = 0.432, 95 % CI = 0.198-0.944), and lacking social support for walking (OR = 0.383, 95 % CI = 0.154-0.957). CONCLUSION: Given the health benefits, PA promotion must be seen as a national responsibility. In particular, physicians have a major role to play in communicating the importance of PA to their older patients and making discussions about strategies for overcoming barriers to walking an integral part of their clinical encounter with these patients.

Using Walk Score™ and Neighborhood Perceptions to Assess Walking Among Middle-Aged and Older Adults.

We aimed to determine the relationship between neighborhood characteristics (walkability, cohesion/safety) and recommended activity levels among community-dwelling middle-aged and older adults. Subjective and objective data on 394 individuals aged ≥50 years were used to assess the likelihood of walking ≥150 min/week. Environmental factors associated with a greater likelihood of any walking ≥150 min/week included living in a neighborhood with high perception of cohesion/safety versus low, living in walkable areas versus car-dependent, and living in an area with a low-moderate median income versus the lowest. Middle-aged and older adults were more likely to walk ≥150 min/week in a walkable, perceived safe/cohesive neighborhood. Identifying neighborhood factors associated with promoting walking among this population can enable stakeholders (e.g., researchers, planners, and policy makers) to direct interventions focusing on the built environment.

Changing organizational culture: using the CEO cancer gold standard policy initiatives to promote health and wellness at a school of public health.

BACKGROUND: Worksite wellness initiatives for health promotion and health education have demonstrated effectiveness in improving employee health and wellness. We examined the effects of a multifaceted health promotion campaign on organizational capacity to meet requirements to become CEO Cancer Gold Standard Accredited. METHODS: We conducted an online survey to assess perceived organizational values and support for the five CEO Cancer Gold Standard Pillars for cancer prevention: tobacco cessation; physical activity; nutrition; cancer screening and early detection; and accessing information on cancer clinical trials. Baseline and follow-up surveys were sent 6-months apart to faculty, staff, and students at a school of public health to test the impact of a multifaceted health promotion campaign on perceived organizational change. Descriptive analyses were used to characterize percent improvement. Multivariate logistic regression analyses were used to control for participants' university status. RESULTS: The current organizational culture highly supported tobacco cessation at both time points. Significant improvements (p < .05) from baseline to follow-up were observed for questions measuring organizational values for 'prevention, screening, and early detection of cancer' and 'accessing cancer treatment and clinical trials'. CONCLUSIONS: Health promotion and education efforts using multiple approaches were effective to improve perceived organizational values and support for cancer prevention and early detection, and increase access to information about cancer clinical trials. Future studies are needed to examine broader impacts of implementing worksite health promotion initiatives.

Geographic variations in access and utilization of cancer screening services: examining disparities among American Indian and Alaska Native Elders.

BACKGROUND: Despite recommendations for cancer screening for breast and colorectal cancer among the Medicare population, preventive screenings rates are often lower among vulnerable populations such as the small but rapidly growing older American Indian and Alaska Native (AIAN) population. This study seeks to identify potential disparities in the availability of screening services, distance to care, and the utilization of cancer screening services for Medicare beneficiaries residing in areas with a higher concentration of AIAN populations. METHODS: Using the county (n =3,225) as the level of analysis, we conducted a cross-sectional analysis of RTI International's Spatial Impact Factor Data (2012) to determine the level of disparities for AIAN individuals. The outcomes of interest include: the presence of health care facilities in the county, the average distance in miles to the closest provider of mammography and colonoscopy (analyzed separately) and utilization of screening services (percent of adults aged 65 and older screened by county). RESULTS: Counties with higher concentrations of AIAN individuals had greater disparities in access and utilization of cancer screening services. Even after adjusting for income, education, state of residence, population 65 and older and rurality, areas with higher levels of AIAN individuals were more likely to see disparities with regard to health care services related to mammograms (p ≤ .05; longer distance, lower screening) and colonoscopies (p ≤ .05; longer distance, lower screening). CONCLUSIONS: These findings provide evidence of a gap in service availability, utilization and access facing areas with higher levels of AIAN individuals throughout the US. Without adequate resources in place, these areas will continue to have less access to services and poorer health which will be accelerated as the population of older adults grows.

Examining Health Inequities in A1C Control over Time across Individual, Geospatial, and Geopolitical Factors among Adults with Type 2 Diabetes: Analyses of a Sample from One Commercial Insurer in a Southern State.

INTRODUCTION: Type 2 diabetes impacts millions and poor maintenance of diabetes can lead to preventable complications, which is why achieving and maintaining target A1C levels is critical. Thus, we aimed to examine inequities in A1C over time, place, and individual characteristics, given known inequities across these indicators and the need to provide continued surveillance. METHODS: Secondary de-identified data from medical claims from a single payer in Texas was merged with population health data. Generalized Estimating Equations were utilized to assess multiple years of data examining the likelihood of having non-target (>7% and ≥7%, two slightly different cut points based on different sources) and separately uncontrolled (>9%) A1C. Adults in Texas, with a Type 2 Diabetes (T2D) flag and with A1C reported in first quarter of the year using data from 2016 and 2019 were included in analyses. RESULTS: Approximately 50% had A1Cs within target ranges (<7% and ≤7%), with 50% considered having non-target (>7% and ≥7%) A1Cs; with 83% within the controlled ranges (≤9%) as compared to approximately 17% having uncontrolled (>9%) A1Cs. The likelihood of non-target A1C was higher among those individuals residing in rural (vs urban) areas (P < .0001); similar for the likelihood of reporting uncontrolled A1C, where those in rural areas were more likely to report uncontrolled A1C (P < .0001). In adjusted analysis, ACA enrollees in 2016 were approx. 5% more likely (OR = 1.049, 95% CI = 1.002-1.099) to have non-target A1C (≥7%) compared to 2019; in contrast non-ACA enrollees were approx. 4% more likely to have non-target A1C (≥7%) in 2019 compared to 2016 (OR = 1.039, 95% CI = 1.001-1.079). In adjusted analysis, ACA enrollees in 2016 were 9% more likely (OR = 1.093, 95% CI = 1.025-1.164) to have uncontrolled A1C compared to 2019; whereas there was no significant change among non-ACA enrollees. CONCLUSIONS: This study can inform health care interactions in diabetes care settings and help health policy makers explore strategies to reduce health inequities among patients with diabetes. Key partners should consider interventions to aid those enrolled in ACA plans, those in rural and border areas, and who may have coexisting health inequities.

Rural-Urban Differences in Physical Activity Tracking and Engagement in a Web-Based Platform.

OBJECTIVES: Despite the well-established health benefits of regular participation in physical activity, most adults do not meet recommended exercise guidelines. In rural communities, limited local resources and geographic dispersion make engaging in regular activity particularly difficult. Web-based solutions offer a potential solution for addressing physical activity disparities between rural and urban areas. METHODS: This study examined the physical activity logs of users (n = 6695) of a web-based platform called Walk Georgia, comparing residents of metropolitan and nonmetropolitan areas. We tabulated descriptive statistics for variables of interest, cross-tabulated for metropolitan and nonmetropolitan groups. We then used independent-samples t tests to compare logged activity between metropolitan and nonmetropolitan residing user groups. RESULTS: In the analysis of group type (n = 6654), users were more likely to enroll in the program as part of a group than as individuals (n = 4391; 65.9%), particularly for users in metropolitan areas (3558 of 5192; 68.5%). Although the groups shared certain activities, nonmetropolitan residents were more likely than metropolitan residents to engage in maintenance-based activities. Nonmetropolitan residents earned fewer program points for their activity than metropolitan users (P = .007), largely because of lower average exercise difficulty (P < .001). CONCLUSIONS: The web-based platform was effective in helping individuals track physical activity. Despite engaging in similar amounts of physical activity by time, on average, users in nonmetropolitan areas engaged in less rigorous and more maintenance-based tasks than users in metropolitan areas. One strategy for increasing physical activity among rural populations may be to leverage social support provided by group enrollment in such programming.