Exploring barriers and facilitators of implementing an at-home SARS-CoV-2 antigen self-testing intervention: The Rapid Acceleration of Diagnostics-Underserved Populations (RADx-UP) initiatives.

BACKGROUND: Evaluating community-based programs provides value to researchers, funding entities, and community stakeholders involved in program implementation, and can increase program impact and sustainability. To understand factors related to program implementation, we aimed to capture the perspective of community partners engaged in organizing and executing community-engaged programs to distribute COVID-19 at-home tests in underserved communities. METHODS: We conducted semi-structured interviews and focus groups with community-based stakeholders informed by the Outcomes for Implementation Research framework. RESULTS: Findings describe how community-engaged communication and dissemination strategies drove program adoption among grassroots stakeholders. Establishing and sustaining trusted relationships was vital to engaging partners with aligned values and capacity. Respondents characterized the programs as generally feasible and appropriate, and community partners felt capable of delivering the program successfully. However, they also described an increased burden on their workforce and desired more significant support. Respondents recognized the programs' community engagement practices as a critical facilitator of acceptability and impact. DISCUSSION: Implementation evaluation aims to inform current and future community outreach and engagement efforts with best practices. As we continue to inform and advance community-engaged disaster response practice, a parallel reimagining of public health funding mechanisms and timelines could provide a foundation for trust, collaboration, and community resiliency that endures beyond a given crisis.

Building bi-directional referral and communication pathways across the community-clinic divide: Experiences from a systems-informed innovation project in Los Angeles.

Bi-directional communication and referral pathways (BCRPs) between clinics and community-based organizations could promote well-being among vulnerable populations with complex and overlapping health and social needs. While BCRPs are promising, establishing them is complex, involving system and process changes across diverse organizational settings. To date, few models have been implemented or empirically tested. This article describes an innovation and planning project to build a BCRP, linking patients in safety net primary care clinics to a comprehensive suite of community-based health and wellness supports in Los Angeles. During a year-long process, a multi-sector team iteratively engaged data to facilitate learning and improvement. The project proceeded through three distinct, but overlapping, phases: (1) Discovery, (2) Systems Mapping, and (3) BCRP Re-design and Testing, which were coordinated through frequent collaborative meetings. By using a stepwise systems-informed approach to collect and examine data, the team was able to generate new change ideas, dispel assumptions, and make transparent and informed decisions. It was critical to have engagement from both internal partners with knowledge of "on-the-ground" practice realities, and external stakeholders with the fresh perspective needed to identify opportunities and define an improvement agenda. These efforts represent first steps towards implementing sustainable BCRPs and realizing their full potential to dynamically bridge the community-clinic divide and improve population health. Other jurisdictions can learn from and adapt the practical data-driven approach used in Los Angeles to build BCRPs that will be thoroughly operationalized, consistently implemented, and optimized within their own unique contexts.

Clinic- and Community-Based National Diabetes Prevention Programs in Los Angeles.

Clinics and community-based organizations (CBOs) are priority settings for implementing the evidence-based National Diabetes Prevention Program (DPP). Both program settings present theoretical advantages and disadvantages for engaging and helping populations most at risk for diabetes achieve lifestyle change goals. To date, few studies have compared implementation across them. The present study describes participant characteristics and lifestyle change outcomes across a sample of clinic- and community-based National DPPs which delivered services in Los Angeles during 2015 to 2018 (two clinics, two CBOs, combined n = 265 participants). Analyses examined participant gender, age, race/ethnicity, baseline body mass index, and program attributes such as screening method and language of instruction. Negative binomial regression models tested for differences in program attendance, mean weekly physical activity, and percent change in body weight by setting. Overall, participants were largely Hispanic/Latinx (81.51%) and female (90.19%). Programs operated by CBOs engaged other race/ethnic groups including Black participants more frequently than those operated by clinics (20.56% vs. 0%); the latter engaged more men (15.29% vs. 7.22%). Few participants in any setting met the National DPP's weight loss goal (clinic: 15.29%, CBO: 20.00%). Participating in a community-based program was initially associated with higher attendance and mean weekly physical activity, but associations were not significant after adjusting for covariates. Study results have practice implications for National DPP implementation and can help inform future efforts to scale and spread the program in Los Angeles and nationally.

Addressing Challenges to Coordinating the Implementation of Place-Based Chronic Disease Prevention Interventions in Los Angeles.

CONTEXT: Chronic disease prevention initiatives have traditionally been structured to address a single disease, potentially limiting the scope of health impacts. In the past decade, initiatives have increasingly adopted a coordinated approach, in which multiple interventions are intended to work synergistically-often in a bounded geographic area-to address interrelated risk factors and diseases. However, despite increased interest in this coordinated approach, few examples exist of how coordination has been operationalized in local public health practice. IMPLEMENTATION: In 2014, the Los Angeles County Department of Public Health launched the 4-year Chronic Disease Prevention Strategy (CDPS). Through CDPS, the Los Angeles County Department of Public Health implemented a range of environmental, lifestyle change, and health system interventions intended to collectively reduce chronic disease among adults in Los Angeles, with concentrated implementation occurring in 1 high-need neighborhood. EVALUATION: This case study examined the activities undertaken to coordinate across CDPS interventions and documented challenges to these efforts. Data were collected via a document review of programmatic materials and structured conversations with staff leading implementation of CDPS interventions. RESULTS: Document review and structured conversations with staff identified 3 primary coordination activities: (1) collaborating on outreach materials to unify messaging, (2) developing a network of common partners, and (3) investing in shared data collection. Operational challenges identified were disparate short-term objectives across interventions, minimal alignment between clinical practice and CDPS goals, restrictions around bidirectional referrals between organizations, and limited bandwidth among new partners to engage with multiple CDPS interventions. Contextual challenges identified were competing social and political issues, and geographic fluidity regarding where community members sought health resources. CONCLUSION: Developing an initiative-specific coordination plan prior to implementation may help reduce challenges to coordination. Modifications in how health initiatives are funded and structured may be needed: greater flexibility in how funding is administered, and the inclusion of coordination-specific metrics, may enable more robust coordination.

Exploring Reimbursement Options for the National Diabetes Prevention Program: Lessons Learned From a Pilot Project in Los Angeles, 2014-2018.

CONTEXT: Although Medicare and several state Medicaid programs are beginning to cover the cost of delivering the National Diabetes Prevention Program (National DPP), little is known about the logistical challenges to establishing reimbursement options for these services. OBJECTIVE: To describe Los Angeles' experience working with payers to identify and establish reimbursement pathways for National DPP providers. DESIGN: A case study was conducted to identify regional options for covering the costs of the National DPP. SETTING: Los Angeles. PARTICIPANTS: A managed care organization along with selected National DPP providers (those that provide in-person and/or online services) participated in this regional pilot project. INTERVENTION: The Los Angeles County Department of Public Health explored and prototyped reimbursement options for the National DPP, using input from and participation by target health plans (payers) and program providers. MAIN OUTCOME MEASURE: The establishment of a regional reimbursement approach for the National DPP. RESULTS: Pilot project participants weighed the pros and cons of billing (Medicare/Medicaid)/reimbursing for program services directly, ultimately choosing to go with a third-party integrator that worked with payers to handle the administrative process of reimbursing program providers for their services. The integrator negotiated and obtained reimbursements on the behalf of the National DPP providers. CONCLUSIONS: Lessons from this case study suggest an emerging need to build further capacity among National DPP providers, as they are often community-based organizations that are not equipped to bill Medicare/Medicaid directly for services. A third-party integrator represents a viable approach for addressing this logistical issue.

Current practices, facilitators, and barriers experienced by program providers implementing the National Diabetes Prevention Program in Los Angeles County.

Individuals with prediabetes can lower their diabetes risk by participating in the National Diabetes Prevention Program (National DPP), an evidence-based, group lifestyle change program that is taught by a certified lifestyle coach. To date, studies have not explicitly compared National DPP implementation across multiple settings (i.e., types of organizations) to understand comparative setting advantages or challenges to engaging priority groups. The purpose of this study was to gain an in-depth understanding of: (a) the variation in National DPP implementation across clinic, community-based, and digital settings and (b) associated facilitators and barriers. The study focused on three core implementation domains: recruitment, retention, and data reporting. This study used a descriptive, qualitative approach to identify current practices, facilitators, and barriers to National DPP implementation by conducting semistructured key informant interviews in spring 2018 with 12 organizations delivering the National DPP in Los Angeles County. There was a general commonality between in-person settings (clinics and community-based), while the experiences of digital providers were relatively distinct. Recruitment and retention were widely described by all settings as labor- and time-intensive, while data reporting was seen as relatively less burdensome. All respondents reported using multiple recruitment strategies. Lifestyle coaches were seen as key to retention, and they spent substantial time engaging with participants outside of class, which often was not accounted for in program costs. Data reporting was easier for organizations that invested in sophisticated data management systems and had staff with sufficient data experience. This study advances knowledge around the translation of the National DPP in diverse settings in the nation's largest county and highlights opportunities for targeted, setting-specific support.

Local School Wellness Policy as a Means to Advance Whole School, Whole Community, Whole Child: Assessing Alignment in Los Angeles County.

BACKGROUND: District wellness policies provide an avenue to advance the Whole School, Whole Community, Whole Child (WSCC) model. The extent to which wellness policies currently align with WSCC is unclear; to-date, tools have been unavailable to examine this issue. METHODS: We reviewed written health-focused policies among 37 school districts in Los Angeles County in 2017 utilizing a 54-item tool designed to examine the quality of policies in the 10 WSCC domains. Descriptive analyses explored overall and domain-specific comprehensiveness and strength; simple negative binomial regression models examined differences in the policy quality and structure by legislated status. RESULTS: Approximately half of expected policies were present in wellness policies (mean comprehensiveness score = 52.65, ±18.09), < 20% were strong (mean strength score = 16.97, ±8.05). Content in WSCC domains addressed by legislative mandates was significantly more comprehensive and stronger, and more frequently located within the wellness policies, relative to content in non-legislated domains. CONCLUSIONS: Opportunities exist for better alignment of wellness policies with WSCC. Education and health practitioners can utilize the tool developed for this study to identify priority areas where policy support is needed in their jurisdictions. Additional efforts are needed to help schools facilitate and document practice gains around WSCC-aligned policies.

Residential Mobility Among Elementary School Students in Los Angeles County and Early School Experiences: Opportunities for Early Intervention to Prevent Absenteeism and Academic Failure.

School connectedness is closely linked to academic success: students who are engaged at school have better attendance and academic performance, and are less likely to drop out. Residential mobility - having moved homes - can increase the risk of a negative academic trajectory (e.g., absenteeism and academic failure). Increasing housing instability in the United States due to rising housing costs, especially in urban areas, has made residential mobility a growing concern. While existing research has examined residential mobility among students and its connection to long-term consequences such as absenteeism and academic failure, less is known about how residential mobility relates to potential intermediate school experiences (e.g., school disconnectedness, low perceived academic ability, and experiences with school violence and harassment) that contribute to a negative academic trajectory. This study examines associations between residential mobility in elementary school and school experiences in a large urban jurisdiction. Data were collected from a sample of public elementary school students in Los Angeles County (5th grade, n = 5,620) via the California Healthy Kids Survey (2013-2014). Descriptive, Chi-square, multiple logistic regression analyses, and predicted probabilities were performed to examine the relationships between past-year residential mobility and indicators of school connectedness and school-based relationships, perceived academic performance, and exposure to violence and harassment. More than a third (36.6%) of students in the analysis sample moved at least once in the past year. After adjusting for neighborhood and family factors, a higher number of past-year moves was significantly associated with poorer school experiences, including lower odds of school connectedness for high-movers (2+ moves) [adjusted odds ratio (AOR) = 0.77; 95% confidence interval (CI) = 0.68-0.86], compared to non-movers. Movers had lower odds of perceived academic ability (1 move: AOR = 0.72; CI = 0.63-0.83; 2+ moves: AOR = 0.55; CI = 0.44-0.69), but higher odds of exposure to violence and harassment as a victim (1 move: AOR = 1.26, CI = 1.17-1.37; 2+ moves: AOR = 1.34, CI = 1.17-1.54), and as a perpetrator (1 move: AOR = 1.21, CI = 1.08-1.36; 2+ moves: AOR = 1.54, CI = 1.24-1.92). These results highlight the value of developing and implementing strategies that can identify and support students who move at young ages, to prevent student disengagement and promote attendance and academic success early in their life trajectory.

Implementing a Healthy Food Distribution Program: A Supply Chain Strategy to Increase Fruit and Vegetable Access in Underserved Areas.

Increasing access to fresh produce in small retail venues could improve the diet of people in underserved communities. However, small retailers face barriers to stocking fresh produce. In 2014, an innovative distribution program, Community Markets Purchasing Real and Affordable Foods (COMPRA), was launched in Los Angeles with the aim of making it more convenient and profitable for small retailers to stock fresh produce. Our case study describes the key processes and lessons learned in the first 2 years of implementing COMPRA. Considerable investments in staff capacity and infrastructure were needed to launch COMPRA. Early successes included significant week-to-week increases in the volume of produce distributed. Leveraging partnerships, maintaining a flexible operational and funding structure, and broadly addressing store owners' needs contributed to initial gains. We describe key challenges and next steps to scaling the program. Lessons learned from implementing COMPRA could inform other jurisdictions considering supply-side approaches to increase access to healthy food.

Distribution, characteristics, and level of community awareness and use of formal shared use sites in Los Angeles.

Shared use agreements (SUA) could increase opportunities for physical activity (PA) in under-resourced, urban areas. Despite recent investments in SUAs, the extent to which they reach communities in need and the level of community awareness and use of SUAs remains unclear. This cross-sectional study examined: 1) the distribution of SUAs in Los Angeles (LA) during the 2015-2016 academic year, 2) the characteristics of communities where SUAs were located, and 3) the extent to which community members were aware of and using available facilities. Assessment methods included: 1) abstraction of school administrative data reflecting the geographic distribution and scope of SUAs in LA, 2) collation of community-level Census and local planning data to describe demographic characteristics and per capita park acreage of communities where SUAs were located, and 3) collection of data via an Internet panel survey of LA adults (n = 371) examining awareness and use of SUA facilities. Under 3% of schools had a SUA in place during the study period. Compared to other areas of the city, areas within one mile of SUAs had more Hispanic/Latino, low-income, and lower educational status residents. Among survey respondents, 25.6% of those living within one mile of a SUA reported having access to school facilities; 48.6% of those reporting access reported using them. Although potentially targeted in high-needs areas, community members may not be aware of or utilizing SUA facilities. Additional efforts are needed to both expand access to school-based PA resources and attract community users.

Review of Education-Focused Health Impact Assessments Conducted in the United States.

BACKGROUND: Health impact assessment (HIA) provides a structured process for examining the potential health impacts of proposed policies, plans, programs, and projects. This study systematically reviewed HIAs conducted in the United States on prekindergarten, primary, and secondary education-focused decisions. METHODS: Relevant HIA reports were identified from web sources in late 2015. Key data elements were abstracted from each report. Four case studies were selected to highlight diversity of topics, methods, and impacts of the assessment process. RESULTS: Twenty HIAs completed in 2003-2015 from 8 states on issues related to prekindergarten through secondary education were identified. The types of decisions examined included school structure and funding, transportation to and from school, physical modifications to school facilities, in-school physical activity and nutrition, and school discipline and climate. Assessments employed a range of methods to characterize the nature, magnitude, and severity of potential health impacts. Assessments fostered stakeholder engagement and provided health-promoting recommendations, some of which were subsequently incorporated into school policies. CONCLUSIONS: Health impact assessment is a promising tool that education, health, and other stakeholders can use to maximize the health and well-being of students, families, and communities.

A Framework for Implementing the National Diabetes Prevention Program in Los Angeles County.

INTRODUCTION: Preventing type 2 diabetes is a public health priority in the United States. An estimated 86 million Americans aged 20 years or older have prediabetes, 90% of whom are unaware they have it. The National Diabetes Prevention Program (NDPP) has the potential to reduce the incidence of type 2 diabetes; however, little is known about the best way to institutionalize such a program in a jurisdiction with a racially/ethnically diverse population. The objective of this study was to develop a practice-grounded framework for implementing the NDPP in Los Angeles County. METHODS: In 2015, the Los Angeles County Department of Public Health (LACDPH) partnered with Ad Lucem Consulting to conduct a 3-stage formative assessment that consisted of 1) in-depth interviews with key informants representing community-based organizations to learn about their experiences implementing the NDPP and similar lifestyle-change programs and 2) 2 strategic planning sessions to obtain input and feedback from the Los Angeles County Diabetes Prevention Coalition. LACDPH identified core activities to increase identification of people with type 2 diabetes and referral and enrollment of eligible populations in the NDPP. RESULTS: We worked with LACDPH and key informants to develop a 3-pronged framework of core activities to implement NDPP: expanding outreach and education, improving health care referral systems and protocols, and increasing access to and insurance coverage for NDPP. The framework will use a diverse partner network to advance these strategies. CONCLUSION: The framework has the potential to identify people with prediabetes and to expand NDPP among priority populations in Los Angeles County and other large jurisdictions by using a diverse partner network.

Youth Descriptions of Mental Health Needs and Experiences with School-based Services: Identifying Ways to Meet the Needs of Underserved Adolescents.

While schools serve as a common entry point into mental health services for underserved youth, engagement of students in need of care remains a problem. Little is known about the ways schools can best address students' mental health needs, especially from the perspective of youth who struggle to attend school, a vulnerable group with a high burden of mental health problems. A qualitative descriptive approach was used to analyze data from in-depth interviews with a sample of 18 youth with a history of school truancy and mental health problems. Analyses explored how youth expressed mental health symptoms, and their trajectories through, and perceptions of, school-based mental health services. Results suggest that participants experienced multiple, overlapping symptoms; only a portion had their needs addressed. The quality of relationships with school staff and the perceived efficacy of treatment affected service trajectories. Promising school-based approaches to address students' mental health needs are discussed.

Pharmacist-Driven Strategies for Hypertension Management in Los Angeles: A Community and Stakeholder Needs Assessment, 2014-2015.

In 2014, the Los Angeles County Department of Public Health received federal funding to improve the prevention and control of hypertension in the population through team-based health care delivery models, such as pharmacist-led medication therapy management. To inform this work, the department conducted a 3-part needs assessment consisting of 1) a targeted context scan of regional policies and efforts, 2) a key stakeholder survey, and 3) a public opinion internet-panel survey of Los Angeles residents. Results suggest that political will and professional readiness exists for expansion of pharmacist-led medication management strategies in Los Angeles. However, several infrastructure and economic barriers, such as a lack of sufficient payment or reimbursement mechanisms for these services, impede progress. The department is using assessment results to address barriers and shape efforts in scaling up pharmacist-led programming in Los Angeles.

Early Impacts of a Healthy Food Distribution Program on the Availability and Price of Fresh Fruits and Vegetables in Small Retail Venues in Los Angeles.

Healthy food distribution programs that allow small retailers to purchase fresh fruits and vegetables at wholesale prices may increase the profitability of selling produce. While promising, little is known about how these programs affect the availability of fresh fruits and vegetables in underserved communities. This study examined the impacts of a healthy food distribution program in Los Angeles County over its first year of operation (August 2015-2016). Assessment methods included: (1) a brief survey examining the characteristics, purchasing habits, and attitudes of stores entering the program; (2) longitudinal tracking of sales data examining changes in the volume and variety of fruits and vegetables distributed through the program; and (3) the collection of comparison price data from wholesale market databases and local grocery stores. Seventeen stores participated in the program over the study period. One-fourth of survey respondents reported no recent experience selling produce. Analysis of sales data showed that, on average, the total volume of produce distributed through the program increased by six pounds per week over the study period (95% confidence limit: 4.50, 7.50); trends varied by store and produce type. Produce prices offered through the program approximated those at wholesale markets, and were lower than prices at full-service grocers. Results suggest that healthy food distribution programs may reduce certain supply-side barriers to offering fresh produce in small retail venues. While promising, more work is needed to understand the impacts of such programs on in-store environments and consumer behaviors.

Access to and Use of Schools for Physical Activity Among Adults in Los Angeles County.

Formal agreements that outline conditions for community use of school facilities represent a potentially attractive approach to increasing access to places for physical activity in underresourced areas. Despite growing interest in these shared use agreements, limited data are available on their population-level impacts. This study used data collected via an Internet panel survey in spring 2014 (n = 1,006) to examine the extent of public awareness and use of school-based physical activity resources in Los Angeles County. Weighted data were analyzed using logistic regression to examine associations among access to and use of schools, demographics, and behavioral and environmental factors. Negative binomial regression was performed to test the association between access to school-based physical activity resources and physical activity. Results suggest that a large percentage (57.7%) of people have access to school-based physical activity resources; however, only a portion (30.3%) use them. Safety of school grounds and whether onsite programming was offered were positively associated with use. In light of these findings, additional efforts may be needed to help optimize community use of schools for physical activity. These results can help inform program planning and implementation in communities considering shared use policies.

The Association between Self-Reported Grocery Store Access, Fruit and Vegetable Intake, Sugar-Sweetened Beverage Consumption, and Obesity in a Racially Diverse, Low-Income Population.

This study sought to examine the relationship between self-reported time and distance to the nearest retail grocery store, healthy and unhealthy food consumption, and objectively measured body mass index (BMI). We conducted a survey with 1,503 racially diverse, low-income residents at five public health centers in Los Angeles County. Most participants reported shopping at a supermarket (86.7%) and driving (59.9%) to their usual source for groceries. Over half reported living less than a mile from (58.9%) and traveling 5 min or less to reach (50.3%) the nearest grocery store. In the multivariable regression models, neither self-reported distance nor time to the nearest grocery store was consistently associated with fruit and vegetable intake, sugar-sweetened beverage consumption, or BMI. Results suggest that the need to consider access and quality as well as urban planning and transportation, when examining the relationship between the retail food environment and health outcomes.