Evaluating community-driven cardiovascular health policy changes in the United States using agent-based modeling.

Comprehensive smoke-free policy is a strategy to prevent cardiovascular disease (CVD) at a population-level; however, evaluating their long-term outcomes is difficult. This study used an agent-based model to estimate long-term impacts of a comprehensive smoke-free policy, as it was implemented in two communities, Arlington and Mesquite, Texas. The model predicted the percentage of myocardial infarction (MI), stroke, and diabetes in the population 10 and 20 years following policy adoption. In Arlington, the percentage of the population with these conditions each decreased by approximately 0.5% over 20 years; in Mesquite, the percentage of the population with diabetes, myocardial infarction (MI), and stroke decreased by 1.1%, 0.6%, and 0.3%, respectively, after 20 years. The results were statistically significant (p < 0.001). As an evaluation strategy, agent-based modeling can help researchers and practitioners estimate the potential long-term effects of policies and garner intervention support for implementation.

Highlighting Contributions of Behavioral and Social Sciences in Advancing Public Health: Where We've Come, Where We're Headed.

CONTEXT: Social and behavioral sciences, a cross-disciplinary field that examines the interaction among behavioral, biological, environmental, and social factors, has contributed immensely to some public health achievements over the last century. Through collaboration with community organizations and partners, social and behavioral scientists have conducted numerous program interventions involving community engagement and advocacy efforts at the local, state, federal, and international levels. CONTRIBUTIONS OF SOCIAL AND BEHAVIORAL SCIENCES: This article traces select historical underpinnings of the applications of social and behavioral sciences theories and evidence to public health and highlights 4 areas in which health education specialists have distinctly contributed to public health achievements by building on theory and evidence. Applied social and behavioral sciences have formed the basis of various health education interventions. These 4 areas include the following: (1) Theory, Model Development, and the Professionalization of Health Education; (2) Participation and Community Engagement; (3) Health Communication; and (4) Advocacy and Policy. DISCUSSION: We present contemporary challenges and recommendations for strengthening the theory, research, and practice of health education within the context of social and behavioral sciences in addressing emerging public health issues.

Interorganizational network findings from a nationwide cardiovascular disease prevention initiative.

OBJECTIVES: To use network analysis in order to evaluate the effectiveness of interorganizational networks in implementing policy, systems, and environmental interventions for cardiovascular disease prevention throughout the United States. METHODS: Evaluators conducted an interorganizational network (ION) survey to examine information sharing and joint planning within organizational relationships in 15 community-based cardiovascular disease prevention partnership networks. Density and betweenness centrality scores at the node- and network-level were calculated for each partnership network using UCINET© network analysis software. Common data patterns were then extracted using a multiple case study format. RESULTS: Network density scores ranged from 0.50 to 1.00 (M = 0.84, SD = 0.14) for information sharing and 0.43-1.00 (M = 0.77, SD = 0.15) for joint planning. Centralization indices ranged from 0.00 to 0.11 (M = 0.04, SD = 0.03), and 0.00-0.17 (M = 0.06, SD = 0.05), respectively. Overall, 73.33 % of communities were successful in meeting their partnership goals. CONCLUSIONS: When planning and implementing interorganizational networks, high betweenness centrality and more hierarchically structured networks were identified as the most salient partnership characteristics to programmatic success. The network findings were triangulated with previously published qualitative data to provide context. These findings provide valuable insight on how national networks can be designed and leveraged to implement systematic community health projects.

Understanding innovation in health program planning and development.

INTRODUCTION: A need for innovative public health programs is evident as the field adapts to address changes in health priorities and target populations. The Innovative Teen Pregnancy Prevention Program (iTP3) was created to support and enable innovation in teenage pregnancy prevention, developing programs to reach the most at risk youth. METHODS: A formative evaluation was conducted to understand what innovation means in the context of program development, and examine the process of innovation. Qualitative data was collected through baseline interviews with program development teams, referred to as Innovators, prior to the start of the project period and follow-up interviews conducted at the end of a 12-month funding period. Additional open-ended written responses were collected in the middle of the funding cycle. A thematic analysis with an open-coding scheme was used to identify emergent themes. RESULTS: Innovators considered programs innovative because of the target population of focus, program delivery mechanism, and/or program development approach. They specifically identified that a "culture" of innovation must be present if new programs are to be developed. Over time, Innovators began to shift their definition of innovation toward unique design processes and ecological approaches. DISCUSSION: Through creating a culture of innovation and utilizing systems thinking, this project provides important insights in how to develop innovations in public health.

Ecological Approaches to Teen Pregnancy Prevention: An Examination of Evidence-Based Interventions.

Over the past 20 years, teenage birth rates in the United States have declined substantially but continue to persist among certain populations. During this time period, a series of rigorously tested teen pregnancy prevention (TPP) programs were developed, and a number of evidence-based interventions (EBIs) emerged. In April 2017, researchers reviewed EBIs in TPP and examined each program's socioecological levels of intervention, measurements approaches, and other ecological aspects. Findings indicate that the majority of TPP EBIs are aimed at the individual and/or interpersonal level of intervention. Furthermore, the programs were evaluated using the individual as the unit of analysis, regardless of what level the EBI targets. These findings represent serious gaps, specifically a lack of system-, environmental-, and policy-level EBIs. Future TP approaches should target multiple levels of social ecology, ensure measurements appropriately capture changes within these levels, and shift to a focus on a longer term population health improvement.

Implementation of Policy, Systems, and Environmental Community-Based Interventions for Cardiovascular Health Through a National Not-for-Profit: A Multiple Case Study.

INTRODUCTION: In 2014, the Centers for Disease Control and Prevention funded the American Heart Association to implement policy, systems, and environment-focused strategies targeting access to healthy food and beverages, physical activity, and smoke-free environments. METHOD: To understand factors affecting implementation and variations in success across sites, evaluators conducted a multiple case study. Based on past literature, community sites were categorized as capacity-building or implementation-ready, for comparison. A sample of six communities were selected using a systematic selection tool. Through site visits, evaluators conducted interviews with program staff and community partners and assessed action plans. RESULTS: Evaluators identified important implications for nationally coordinated community-based prevention programming. Differences in implementation varied by the communities' readiness, with the most notable differences in how they planned activities and defined success. Existing partner relationships (or lack thereof) played a significant role, regardless of the American Heart Association's existing presence within the communities, in the progression of initiatives and the differences observed among phases. Last, goals in capacity-building sites were tied to organizational goals while goals in implementation-ready sites were more incremental with increased community influence and buy-in. DISCUSSION: Using national organizations as a mechanism to carry out large-scale community-based prevention work is a viable option that provides coordinated, wide-scale implementation without sacrificing a community's priorities or input. In funding future initiatives, the presence of relationships and the time needed to cultivate such relationships should be accounted for in the planning and implementation processes, as well as both local and national expectations.

Evaluation of Community-Based Policy, Systems, and Environment Interventions Targeting the Vending Machines.

The American Heart Association conducted policy, systems, and environmental (PSE) focused interventions to increase healthy vending in 8 communities. PSE interventions were assessed using the Nutrition Environment Measures Survey Vending Assessment to see changes in the food environment. Baseline and follow-up assessments were conducted with 3 settings and a total of 19 machines. PSE changes resulted in increased availability of healthy options and decreased unhealthy options. Implementation of PSE interventions targeting the food environment can be an effective method of providing increased access to healthy foods and beverages with the goal of increasing consumption to decrease chronic diseases.

Common and Critical Components Among Community Health Assessment and Community Health Improvement Planning Models.

Community health assessment and community health improvement planning are continuous, systematic processes for assessing and addressing health needs in a community. Since there are different models to guide assessment and planning, as well as a variety of organizations and agencies that carry out these activities, there may be confusion in choosing among approaches. By examining the various components of the different assessment and planning models, we are able to identify areas for coordination, ways to maximize collaboration, and strategies to further improve community health. We identified 11 common assessment and planning components across 18 models and requirements, with a particular focus on health department, health system, and hospital models and requirements. These common components included preplanning; developing partnerships; developing vision and scope; collecting, analyzing, and interpreting data; identifying community assets; identifying priorities; developing and implementing an intervention plan; developing and implementing an evaluation plan; communicating and receiving feedback on the assessment findings and/or the plan; planning for sustainability; and celebrating success. Within several of these components, we discuss characteristics that are critical to improving community health. Practice implications include better understanding of different models and requirements by health departments, hospitals, and others involved in assessment and planning to improve cross-sector collaboration, collective impact, and community health. In addition, federal and state policy and accreditation requirements may be revised or implemented to better facilitate assessment and planning collaboration between health departments, hospitals, and others for the purpose of improving community health.

A Mixed-Methods Approach to Understanding Community Participation in Community Health Needs Assessments.

CONTEXT: Nonprofit hospitals are exempt from paying taxes. To maintain this status, they must provide benefit to the community they serve. In an attempt to improve accountability to these communities and the federal government, the Patient Protection and Affordable Care Act of 2010 includes a provision that requires all nonprofit hospitals to conduct a community health needs assessment (CHNA) and implement strategies to address identified health priorities every 3 years. This Act's provision, operationalized by a regulation developed and enforced by the Internal Revenue Service, mandates the involvement of public health agencies and other community stakeholders in the completion of the CHNA. OBJECTIVE: To better understand community participation in nonprofit hospital-directed community health assessment and health improvement planning activities. DESIGN: Using a 2-phased, mixed-methods study design, we (1) conducted content analysis of 95 CHNA/implementation plan reports and (2) interviewed hospital and health system key informants, consultants, and community stakeholders involved in CHNA and planning processes. Community participation was assessed in terms of types of stakeholders involved and the depth of their involvement. RESULTS: Our findings suggest that many hospitals engaged and involved community stakeholders in certain aspects of the assessment process, but very few engaged a broad array of community stakeholder and community members in meaningful participation throughout the CHNA and health improvement planning process. Vast improvements in community participation and collaborative assessment and planning can be made in future CHNAs. CONCLUSIONS: On the basis of the findings, recommendations are made for further research. Practice implications include expanding community engagement and participation by stakeholder and activity type and using a common community health improvement model that better aligns hospital CHNA processes and implementation strategies with other organizations and agencies.

Using a Community Health Development Framework to Increase Community Capacity: A Multiple Case Study.

The Physical Activity and Community Engagement Project utilized a comparative case study to understand how a theoretical framework called community health development (CHD) influences community capacity. Three rural communities (cases) developed interventions using a CHD framework. Researchers collected qualitative evidence measuring capacity and the CHD process for more than 3 years. Patterns identified seven capacity constructs relevant to CHD, including community history, civic participation, leadership, skills, resources, social and interorganizational networks, and critical reflection. Community health development focuses on population health improvement and strengthening community capacity. As such, it helps communities address local priorities and equips them to address future issues.

Adolescent Social Networks and Alcohol Use: Variability by Gender and Type.

BACKGROUND: Scientists have established that social networks influence adolescents' substance use behavior, an influence that varies by gender. However, the role of gender in this mechanism of influence remains poorly understood. Particularly, the role an adolescent's gender, alongside the gender composition of his/her network, plays in facilitating or constraining alcohol use is still unclear. OBJECTIVES: This study examined the associations among the gender composition of adolescents' networks, select network characteristics, intrapersonal and interpersonal factors, and alcohol use among a sample of adolescents in the United States. METHODS: We assessed cross-sectional data from a 2010 study of 1,523 high school students from a school district in Los Angeles. Analyses of adolescents' network characteristics were conducted using UCINET 6; and logistic regression analyses testing the associations between gender composition of the network and alcohol use were conducted using SPSS 20. RESULTS: Our results indicate that the gender composition of adolescents' networks in our sample is associated with alcohol use. Adolescents in predominantly female or predominantly male friendship networks were less likely to report alcohol use compared to adolescents in an equal/balanced network. In addition, depending upon the context/type of network, intrapersonal and interpersonal factors varied in their association with alcohol use. Conclusions/Importance: Based on these findings, we make several recommendations for the future research. We call for researchers to further examine gender as a risk factor for alcohol abuse, particularly within the complex interplay between gender and network contexts.

Scientific Reporting: Raising the Standards.

This article is based on a presentation that was made at the 2014 annual meeting of the editorial board of Health Education & Behavior. The article addresses critical issues related to standards of scientific reporting in journals, including concerns about external and internal validity and reporting bias. It reviews current reporting guidelines, effects of adopting guidelines, and offers suggestions for improving reporting. The evidence about the effects of guideline adoption and implementation is briefly reviewed. Recommendations for adoption and implementation of appropriate guidelines, including considerations for journals, are provided.

The Role of Gender in Adolescents' Social Networks and Alcohol, Tobacco, and Drug Use: A Systematic Review.

BACKGROUND: Despite previous research indicating an adolescents' alcohol, tobacco, and other drug (ATOD) use is dependent upon their sex and the sex composition of their social network, few social network studies consider sex differences and network sex composition as a determinant of adolescents' ATOD use behavior. METHODS: This systematic literature review examining how social network analytic studies examine adolescent ATOD use behavior is guided by the following research questions: (1) How do studies conceptualize sex and network sex composition? (2) What types of network affiliations are employed to characterize adolescent networks? (3) What is the methodological quality of included studies? After searching several electronic databases (PsycINFO, EBSCO, and Communication Abstract) and applying our inclusion/exclusion criteria, 48 studies were included in the review. RESULTS: Overall, few studies considered sex composition of networks in which adolescents are embedded as a determinant that influences adolescent ATOD use. Although included studies all exhibited high methodological quality, the majority only used friendship networks to characterize adolescent social networks and subsequently failed to capture the influence of other network types, such as romantic networks. CONCLUSIONS: School-based prevention programs could be strengthened by (1) selecting and targeting peer leaders based on sex, and (2) leveraging other types of social networks beyond simply friendships.

Community Health Needs Assessment: Potential for Population Health Improvement.

Derived from various health care policies and initiatives, the concept of population health has been newly adopted by health care and medicine. In particular, it has been suggested that the Patient Protection and Affordable Care Act provision that requires nonprofit hospitals to conduct a community health needs assessment (CHNA) and implement strategies to address health priorities has the potential to improve population health. A mixed methods study design was used to examine the potential for population health improvements to occur through the Internal Revenue Service (IRS)-mandated nonprofit hospital CHNA and planning processes. Methods involved a 2-phased approach composed of (1) content analysis of 95 CHNA/implementation strategies reports and (2) interviews with key informants, consultants, and community stakeholders involved in CHNA and planning processes. Although this is a great opportunity for the nonprofit hospital assessment and planning processes to influence population health outcomes, the findings from the first 3-year assessment and planning cycle (2011-2013) suggest this is unlikely. As nonprofit hospitals begin the second 3-year assessment and planning cycle, this article offers recommendations to increase the potential for nonprofit hospitals to improve population health. These recommendations include clarifying the purpose of IRS CHNA regulations, engaging community stakeholders in collaborative assessment and planning, understanding disease etiology and identifying and addressing broader determinants of health, adopting a public health assessment and planning model, and emphasizing population health improvement. (Population Health Management 2016;19:178-186).

A Qualitative Examination of Exergame Motivations in Geocaching.

INTRODUCTION: Exergames are an innovative type of physical activity that engages participants through interactive gameplay. One exergame growing in popularity is geocaching. Geocaching is a high-tech treasure hunt that uses GPS-enabled technology to locate hidden caches. Caches are hidden all over the world, and their coordinates are listed in an online forum ( Geocaching.com ). Exergames like geocaching are widely endorsed; however, there is a lot of information that still needs to be learned about why people participate in these activities. MATERIALS AND METHODS: Thirty-four current geocachers were recruited from a larger geocaching study to learn about their motivations for engaging in the game. Individuals were asked to respond to a 30-minute phone interview, and 12 both consented and participated the interviews. Interviews assessed how individuals became involved in geocaching, how frequently they participated, who they went geocaching with, and their motivations behind geocaching. Interviews were recorded and then thematically coded. RESULTS: The majority of participants had geocached for more than 5 years and had learned about the activity through media. All 12 participants geocached at least once a week. The primary motivations behind geocaching were being outdoors, social interaction, physical activity, and relaxation. Individuals described geocaching as being part of a community. They typically made friends while geocaching or when they were on Geocaching.com and felt connected to other geocachers through their mutual interest. CONCLUSIONS: Geocaching and other exergames that use game-like properties to engage users, specifically though technology, have the potential to impact individual health through nontraditional methods of activity and socialization.

Using Community-Based Participatory Research to Disseminate a Mass Media Campaign Into Rural Communities.

The authors present the results of a media documentary, Weight of the Nation, disseminated in rural communities in the Brazos Valley region of east central Texas. Researchers relied on a community-based participatory research strategy to assure community participation in the implementation and evaluation of the media documentary in rural communities. To measure the short-term effects of the documentary, the research team used a mixed-methods approach of quantitative panel data from a pre/post survey, qualitative meeting notes, and observations from facilitated discussion groups. Results showed short-term increases in behavioral intention, as well as an increase in self and collective efficacy of participants to make healthy changes at individual and community levels to reduce obesity. The findings suggest that Weight of the Nation is a catalyst for increasing awareness about obesity and initiating changes in intention and efficacy perceptions.

Upending the social ecological model to guide health promotion efforts toward policy and environmental change.

Efforts to change policies and the environments in which people live, work, and play have gained increasing attention over the past several decades. Yet health promotion frameworks that illustrate the complex processes that produce health-enhancing structural changes are limited. Building on the experiences of health educators, community activists, and community-based researchers described in this supplement and elsewhere, as well as several political, social, and behavioral science theories, we propose a new framework to organize our thinking about producing policy, environmental, and other structural changes. We build on the social ecological model, a framework widely employed in public health research and practice, by turning it inside out, placing health-related and other social policies and environments at the center, and conceptualizing the ways in which individuals, their social networks, and organized groups produce a community context that fosters healthy policy and environmental development. We conclude by describing how health promotion practitioners and researchers can foster structural change by (1) conveying the health and social relevance of policy and environmental change initiatives, (2) building partnerships to support them, and (3) promoting more equitable distributions of the resources necessary for people to meet their daily needs, control their lives, and freely participate in the public sphere.

Nonprofit hospitals' approach to community health needs assessment.

OBJECTIVES: We sought a better understanding of how nonprofit hospitals are fulfilling the community health needs assessment (CHNA) provision of the 2010 Patient Protection and Affordable Care Act to conduct CHNAs and develop CHNA and implementation strategies reports. METHODS: Through an Internet search of an estimated 179 nonprofit hospitals in Texas conducted between December 1, 2013, and January 5, 2014, we identified and reviewed 95 CHNA and implementation strategies reports. We evaluated and scored reports with specific criteria. We analyzed hospital-related and other report characteristics to understand relationships with report quality. RESULTS: There was wide-ranging diversity in CHNA approaches and report quality. Consultant-led CHNA processes and collaboration with local health departments were associated with higher-quality reports. CONCLUSIONS: At the time of this study, the Internal Revenue Service had not yet issued the final regulations for the CHNA requirement. This provides an opportunity to strengthen the CHNA guidance for the final regulations, clarify the purpose of the assessment and planning process and reports, and better align assessment and planning activities through a public health framework.

Behavioral and technological interventions targeting glycemic control in a racially/ethnically diverse population: a randomized controlled trial.

BACKGROUND: Diabetes self-care by patients has been shown to assist in the reduction of disease severity and associated medical costs. We compared the effectiveness of two different diabetes self-care interventions on glycemic control in a racially/ethnically diverse population. We also explored whether reductions in glycated hemoglobin (HbA1c) will be more marked in minority persons. METHODS: We conducted an open-label randomized controlled trial of 376 patients with type 2 diabetes aged ≥18 years and whose last measured HbA1c was ≥7.5% (≥58 mmol/mol). Participants were randomized to: 1) a Chronic Disease Self-Management Program (CDSMP; n = 101); 2) a diabetes self-care software on a personal digital assistant (PDA; n = 81); 3) a combination of interventions (CDSMP + PDA; n = 99); or 4) usual care (control; n = 95). Enrollment occurred January 2009-June 2011 at seven regional clinics of a university-affiliated multi-specialty group practice. The primary outcome was change in HbA1c from randomization to 12 months. Data were analyzed using a multilevel statistical model. RESULTS: Average baseline HbA1c in the CDSMP, PDA, CDSMP + PDA, and control arms were 9.4%, 9.3%, 9.2%, and 9.2%, respectively. HbA1c reductions at 12 months for the groups averaged 1.1%, 0.7%, 1.1%, and 0.7%, respectively and did not differ significantly from baseline based on the model (P = .771). Besides the participants in the PDA group reporting eating more high-fat foods compared to their counterparts (P < .004), no other significant differences were observed in participants' diabetes self-care activities. Exploratory sub-analysis did not reveal any marked reductions in HbA1c for minority persons but rather modest reductions for all racial/ethnic groups. CONCLUSIONS: Although behavioral and technological interventions can result in some modest improvements in glycemic control, these interventions did not fare significantly better than usual care in achieving glycemic control. More research is needed to understand how these interventions can be most effective in clinical practice. The reduction in HbA1c levels found in our control group that received usual care also suggests that good routine care in an integrated healthcare system can lead to better glycemic control. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01221090.