Enablers and Barriers to Implementing ICU Follow-Up Clinics and Peer Support Groups Following Critical Illness: The Thrive Collaboratives.

OBJECTIVES: Data are lacking regarding implementation of novel strategies such as follow-up clinics and peer support groups, to reduce the burden of postintensive care syndrome. We sought to discover enablers that helped hospital-based clinicians establish post-ICU clinics and peer support programs, and identify barriers that challenged them. DESIGN: Qualitative inquiry. The Consolidated Framework for Implementation Research was used to organize and analyze data. SETTING: Two learning collaboratives (ICU follow-up clinics and peer support groups), representing 21 sites, across three continents. SUBJECTS: Clinicians from 21 sites. MEASUREMENT AND MAIN RESULTS: Ten enablers and nine barriers to implementation of "ICU follow-up clinics" were described. A key enabler to generate support for clinics was providing insight into the human experience of survivorship, to obtain interest from hospital administrators. Significant barriers included patient and family lack of access to clinics and clinic funding. Nine enablers and five barriers to the implementation of "peer support groups" were identified. Key enablers included developing infrastructure to support successful operationalization of this complex intervention, flexibility about when peer support should be offered, belonging to the international learning collaborative. Significant barriers related to limited attendance by patients and families due to challenges in creating awareness, and uncertainty about who might be appropriate to attend and target in advertising. CONCLUSIONS: Several enablers and barriers to implementing ICU follow-up clinics and peer support groups should be taken into account and leveraged to improve ICU recovery. Among the most important enablers are motivated clinician leaders who persist to find a path forward despite obstacles.

Mass Media Campaign to Reduce Consumption of Sugar-Sweetened Beverages in a Rural Area of the United States.

OBJECTIVES: To evaluate a mass media campaign to reduce the consumption of sugar-sweetened beverages (SSBs). METHODS: We disseminated messages emphasizing the health risks of SSBs through television, digital channels, and local organizations over 15 weeks in 2015-2016 in the Tri-Cities region of northeast Tennessee, southwest Virginia, and southeast Kentucky. We evaluated the campaign with pre- and post-telephone surveys of adults aged 18 to 45 years in the intervention area and by examining changes in beverage sales in the intervention and a matched comparison area in western Virginia. RESULTS: Fifty-four percent of postcampaign respondents recalled seeing a campaign advertisement. After the campaign, 53% of respondents believed SSBs were a cause of heart disease, and respondents were more likely postcampaign to consider SSBs a "big cause of diabetes" (75% vs 60%; P < .001). Compared with 12 months before, after the start of the campaign, SSB sales decreased 3.4%, including a 4.1% decrease in soda sales in the intervention area relative to the comparison area (P < .01). CONCLUSIONS: This brief media campaign on SSBs was followed by intended changes in beliefs and consumption. Public Health Implications. Additional media campaigns on SSBs should be attempted and evaluated.

Reducing sugary drink consumption: New York City's approach.

Studies have linked the consumption of sugary drinks to weight gain, obesity, and type 2 diabetes. Since 2006, New York City has taken several actions to reduce consumption. Nutrition standards limited sugary drinks served by city agencies. Mass media campaigns educated New Yorkers on the added sugars in sugary drinks and their health impact. Policy proposals included an excise tax, a restriction on use of Supplemental Nutrition Assistance Program benefits, and a cap on sugary drink portion sizes in food service establishments. These initiatives were accompanied by a 35% decrease in the number of New York City adults consuming one or more sugary drinks a day and a 27% decrease in public high school students doing so from 2007 to 2013.

Decrease in rate of opioid analgesic overdose deaths - Staten Island, New York City, 2011-2013.

From 2000 to 2011, the rate of unintentional drug poisoning (overdose) deaths involving opioid analgesics increased 435% in Staten Island, from 2.0 to 10.7 per 100,000 residents. During 2005-2011, disparities widened between Staten Island and the other four New York City (NYC) boroughs (Bronx, Brooklyn, Manhattan, and Queens); in 2011, the rate in Staten Island was 3.0-4.5 times higher than in the other boroughs. In response, the NYC Department of Health and Mental Hygiene (DOHMH) implemented a comprehensive five-part public health strategy, with both citywide and Staten Island-targeted efforts: 1) citywide opioid prescribing guidelines, 2) a data brief for local media highlighting Staten Island mortality and prescribing data, 3) Staten Island town hall meetings convened by the NYC commissioner of health and meetings with Staten Island stakeholders, 4) a Staten Island campaign to promote prescribing guidelines, and 5) citywide airing of public service announcements with additional airing in Staten Island. Concurrently, the New York state legislature enacted the Internet System for Tracking Over-Prescribing (I-STOP), a law requiring prescribers to review the state prescription monitoring system before prescribing controlled substances. This report describes a 29% decline in the opioid analgesic-involved overdose death rate in Staten Island from 2011 to 2013, while the rate did not change in the other four NYC boroughs, and compares opioid analgesic prescribing data for Staten Island with data for the other boroughs. Targeted public health interventions might be effective in lowering opioid analgesic-involved overdose mortality rates.

Preventing childhood obesity: what are we doing right?

After decades of increases, the prevalence of childhood obesity has declined in the past decade in New York City, as measured in children participating in the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and public school students, with the greatest reductions occurring in the youngest children. Possible explanations were changes in demographics; WIC, day care, and school food policies; citywide obesity prevention policies, media messages; and family and community food consumption. Although the decreases cannot be attributed to any one cause, the most plausible explanation is changes in food consumption at home, prompted by media messages and reinforced by school and child care center policy changes. Continued media messages and policy changes are needed to sustain these improvements and extend them to other age groups.

Sodium intake in a cross-sectional, representative sample of New York City adults.

OBJECTIVES: We estimated sodium intake, which is associated with elevated blood pressure, a major risk factor for cardiovascular disease, and assessed its association with related variables among New York City adults. METHODS: In 2010 we conducted a cross-sectional, population-based survey of 1656 adults, the Heart Follow-Up Study, that collected self-reported health information, measured blood pressure, and obtained sodium, potassium, and creatinine values from 24-hour urine collections. RESULTS: Mean daily sodium intake was 3239 milligrams per day; 81% of participants exceeded their recommended limit. Sodium intake was higher in non-Hispanic Blacks (3477 mg/d) and Hispanics (3395 mg/d) than in non-Hispanic Whites (3066 mg/d; both P < .05). Higher sodium intake was associated with higher blood pressure in adjusted models, and this association varied by race/ethnicity. CONCLUSIONS: Higher sodium intake among non-Hispanic Blacks and Hispanics than among Whites was not previously documented in population surveys relying on self-report. These results demonstrate the feasibility of 24-hour urine collection for the purposes of research, surveillance, and program evaluation.

Cost comparison of 2 mass vaccination campaigns against influenza A H1N1 in New York City.

Objectives. We estimated and compared total costs and costs per dose administered for 2 influenza A 2009 monovalent vaccine campaigns in New York City: an elementary school-located campaign targeting enrolled children aged 4 years and older, and a community-based points-of-dispensing campaign for anyone aged 4 years and older. Methods. We determined costs from invoices or we estimated costs. We obtained vaccination data from the Citywide Immunization Registry and reports from the community points of dispensing. Results. The school campaign delivered approximately 202,089 vaccines for $17.9 million and $88 per dose. The community campaign delivered 49,986 vaccines for $7.6 million and $151 per dose. At projected capacity, the school campaign could have delivered 371,827 doses at $53 each or $13 each when we excluded the value of in-kind resources. The community points of dispensing could have administered 174,000 doses at $51 each or $24 each when we excluded the value of in-kind resources. Conclusions. The school campaign delivered vaccines at a lower cost per dose than did the community campaign. Had demand been higher, both campaigns may have delivered vaccine at lower, more comparable cost per dose.

Effect of changes to the neighborhood built environment on physical activity in a low-income African American neighborhood.

INTRODUCTION: Obesity is a public health problem that is due in part to low levels of physical activity. Physical activity levels are influenced by the built environment. We examined how changes in the built environment affected residents' physical activity levels in a low-income, primarily African American neighborhood in New Orleans. METHODS: We built a 6-block walking path and installed a school playground in an intervention neighborhood. We measured physical activity levels in this neighborhood and in 2 matched comparison neighborhoods by self-report, using door-to-door surveys, and by direct observations of neighborhood residents outside before (2006) and after (2008) the interventions. We used Pearson χ² tests of independence to assess bivariate associations and logistic regression models to assess the effect of the interventions. RESULTS: Neighborhoods were comparable at baseline in demographic composition, choice of physical activity locations, and percentage of residents who participated in physical activity. Self-reported physical activity increased over time in most neighborhoods. The proportion of residents observed who were active increased significantly in the section of the intervention neighborhood with the path compared with comparison neighborhoods. Among residents who were observed engaging in physical activity, 41% were moderately to vigorously active in the section of the intervention neighborhood with the path compared with 24% and 38% in the comparison neighborhoods at the postintervention measurement (P < .001). CONCLUSION: Changes to the built environment may increase neighborhood physical activity in low-income, African American neighborhoods.

Public health research: lost in translation or speaking the wrong language?

Public health leaders, like physicians, need to make decisions that impact health based on strong evidence. To generate useful evidence for public health leaders, research must focus on interventions that have potential to impact population-level health. Often policy and environmental changes are the interventions with the greatest potential impact on population health, but studying these is difficult because of limitations in the methods typically used and emphasized in health research. To create useful evidence for policy and environmental interventions, other research methods are needed, including observational studies, the use of surveillance data for evaluation, and predictive mathematical modeling. More emphasis is needed on these types of study designs by researchers, funding agencies, and scientific journals.

The rationale behind small food store interventions in low-income urban neighborhoods: insights from New Orleans.

Environmental approaches to the obesity problem in the US have garnered favor due to growing evidence that changes to the environment are at the root of the epidemic. Low-income urban neighborhoods, where obesity rates are disproportionately high, typically lack supermarkets yet have a high density of small food stores. This may increase the risk for unhealthy diets and obesity for neighborhood residents, because small stores carry mostly energy-dense foods and few fruits and vegetables. This paper pulls together various studies and pilot work conducted in New Orleans to explore the rationale behind small store interventions. Many low-income residents in New Orleans live within walking distance of small food stores and shop at them frequently. Marketing research has documented that changes to in-store shelf space and displays of specific foods affect the sales of these foods. Initiatives in New Orleans and elsewhere have demonstrated some success with improving healthy food availability in small stores, and an intercept survey of customers at small stores suggests that customers would purchase more fruits and vegetables if available. Efforts to encourage small store operators to offer a healthier mix of foods may, in the end, depend on the profitability of such changes. Evidence from a typical small store in New Orleans indicates that a greater percentage of gross profits come from snack foods and beverages than from fruits and vegetables. More research is needed to better understand the financial operations of small food stores and whether altering the mix of foods is economically feasible.

The ubiquity of energy-dense snack foods: a national multicity study.

OBJECTIVES: We assessed the availability and accessibility of energy-dense snacks in retail stores whose primary merchandise was not food and whether these varied by store type, region, or socioeconomic factors. METHODS: We conducted systematic observations of 1082 retail stores in 19 US cities and determined the availability and accessibility of 6 categories of energy-dense snack foods. RESULTS: Snack food was available in 41% of the stores; the most common forms were candy (33%), sweetened beverages (20%), and salty snacks (17%). These foods were often within arm's reach of the cash register queue. We observed snack foods in 96% of pharmacies, 94% of gasoline stations, 22% of furniture stores, 16% of apparel stores, and 29% to 65% of other types of stores. Availability varied somewhat by region but not by the racial or socioeconomic characteristics of nearby census tracts. CONCLUSIONS: Energy-dense snack foods and beverages, implicated as contributors to the obesity epidemic, are widely available in retail stores whose primary business is not food. The ubiquity of these products may contribute to excess energy consumption in the United States.

Disparities in food access: does aggregate availability of key foods from other stores offset the relative lack of supermarkets in African-American neighborhoods?

OBJECTIVE: Recent work demonstrates the importance of in-store contents, yet most food access disparity research has focused on differences in store access, rather than the foods they carry. This study examined in-store shelf space of key foods to test whether other types of stores might offset the relative lack of supermarkets in African-American neighborhoods. METHODS: New Orleans census tract data were combined with health department information on food stores open in 2004-2005. Shelf space of fruits, vegetables, and energy-dense snacks was assessed using a measuring wheel and established protocols in a sample of stores. Neighborhood availability of foods was calculated by summing shelf space in all stores within 2km of tract centers. Regression analyses assessed associations between tract racial composition and aggregate food availability. RESULTS: African-American neighborhoods had fewer supermarkets and the aggregate availability of fresh fruits and vegetables was lower than in other neighborhoods. There were no differences in snack food availability. CONCLUSIONS: Other store types did not offset the relative lack of supermarkets in African-American neighborhoods in the provision of fresh produce, though they did for snack foods. Altering the mix of foods offered in such stores might mitigate these inequities.

The association between obesity and urban food environments.

Several studies have examined associations between the food retail environment and obesity, though virtually no work has been done in the urban South, where obesity rates are among the highest in the country. This study assessed associations between access to food retail outlets and obesity in New Orleans. Data on individual characteristics and body weight were collected by telephone interviews from a random sample of adults (N = 3,925) living in New Orleans in 2004-2005. The neighborhood of each individual was geo-mapped by creating a 2-km buffer around the center point of the census tract in which they lived. Food retailer counts were created by summing the total number of each food store type and fast food establishment within this 2-km neighborhood. Hierarchical linear models assessed associations between access to food retailers and obesity status. After adjusting for individual characteristics, each additional supermarket in a respondent's neighborhood was associated with a reduced odds for obesity (OR 0.93, 95% CI 0.88-0.99). Fast food restaurant (OR 1.01, 95% CI 1.00-1.02) and convenience store (OR 1.01, 95% CI 1.00-1.02) access were each predictive of greater obesity odds. An individual's access to food stores and fast food restaurants may play a part in determining weight status. Future studies with longitudinal and experimental designs are needed to test whether modifications in the food environment may assist in the prevention of obesity.