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.

Understanding the Density and Distribution of Restaurants in Los Angeles County to Inform Local Public Health Practice.

INTRODUCTION: To describe the potential reach of restaurant-based strategies that seek to improve the healthfulness of menu options, it is important to understand the local restaurant environment, including the extent to which restaurants subject to policy mandates are located in communities disproportionately affected by diet-related diseases. METHODS: This cross-sectional study examined the restaurant environment in Los Angeles County, a large jurisdiction with diverse geographic and socioeconomic characteristics, specifically 1) the number and characteristics of restaurants; 2) the association between neighborhood sociodemographics and restaurant density; and 3) the association between neighborhood sociodemographics and restaurant characteristics, including chain status (large chain, small chain, independent restaurant). Data sources were 1) industry data on restaurant location and characteristics (N = 24,292 restaurants) and 2) US Census data on neighborhood sociodemographics (N = 247 neighborhoods). We conducted descriptive and bivariate analyses at the restaurant and neighborhood level. RESULTS: Countywide, only 26.5% of all restaurants were part of a large chain (a chain with ≥20 locations). We found positive associations between restaurant density and neighborhood proportions of non-Hispanic white residents and residents with more than a high school education. We found limited support to suggest a greater density of large chains in neighborhoods with lower socioeconomic status. CONCLUSION: Results highlight the potentially limited reach of strategies targeting chain restaurants and point to the importance of including small chain restaurants and independent restaurants in public health efforts to improve the healthfulness of restaurants. Understanding where restaurants are in relation to priority populations is a critical step to planning strategies that address diet-related disparities.

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.

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.

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.

A Practice-Grounded Approach for Evaluating Health in All Policies Initiatives in the United States.

OBJECTIVE: To address the social determinants of health, an increasing number of public health practitioners are implementing Health in All Policies initiatives aimed at increasing cross-sectoral collaboration and integrating health considerations into decisions made by "nonhealth" sectors. Despite the growth in practice nationally and internationally, evaluation of Health in All Policies is a relatively new field. To help inform evaluation of Health in All Policies initiatives in the United States, this study sought to develop a practice-grounded approach, including a logic model and a set of potential indicators, which could be used to describe and assess Health in All Policies activities, outputs, and outcomes. DESIGN: Methods included (a) a review of the literature on current Health in All Policies approaches, practices, and evaluations; and (b) consultation with experts with substantive knowledge in implementing or evaluating Health in All Policies initiatives. Feedback from experts was obtained through individual (n = 11) and group (n = 14) consultation. RESULTS: The logic model depicts a range of potential inputs, activities, outputs, and outcomes of Health in All Policies initiatives; example indicators for each component of the logic model are provided. Case studies from California, Washington, and Nashville highlight emerging examples of Health in All Policies evaluation and the ways in which local context and goals inform evaluation efforts. CONCLUSION: The tools presented in this article synthesize concepts present in the emerging literature on Health in All Policies implementation and evaluation. Practitioners and researchers can use the tools to facilitate dialogue among stakeholders, clarify assumptions, identify how they will assess progress, and implement data-driven ways to improve their Health in All Policies work.

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.

Media Outlet and Consumer Reactions to Promotional Activities of the Choose Health LA Restaurants Program in Los Angeles County.

OBJECTIVE: This study sought to assess promotional activities undertaken to raise public awareness of the Choose Health LA Restaurants program in Los Angeles County, an environmental change strategy that recognizes restaurants for offering reduced-size and healthier menu options. DESIGN: We used multiple methods to assess public awareness of and reactions to the promotional activities, including an assessment of the reach of core promotional activities, a content analysis of earned media, and an Internet panel survey. SETTING: The study was conducted in Los Angeles County, home to more than 10 million residents. PARTICIPANTS: An online survey firm recruited participants for an Internet panel survey; to facilitate generalization of results to the county's population, statistical weights were applied to analyses of the survey data. INTERVENTION: Promotional activities to raise awareness of the program included community engagement, in-store promotion, and a media campaign. MAIN OUTCOME MEASURES: Outcomes included media impressions, the number of people who reported seeing the Choose Health LA Restaurants logo, and a description of the themes present in earned media. RESULTS: Collectively, paid media outlets reported 335 587 229 total impressions. The Internet panel survey showed that 12% of people reported seeing the program logo. Common themes in earned media included the Choose Health LA Restaurants program aims to provide restaurant patrons with more choices, represents a new opportunity for restaurants and public health to work together, will benefit participating restaurants, and will positively impact health. CONCLUSIONS: Promotional activities for the Choose Health LA Restaurants program achieved modest reach and positive reactions from media outlets and consumers. The program strategy and lessons learned can help inform present and future efforts to combine environmental and individually focused strategies that target key influences of consumer food selection.

The Impact of Two Los Angeles County Teen Courts on Youth Recidivism: Comparing Two Informal Probation Programs.

OBJECTIVE: This study sought to examine the impact of two Teen Courts operating in Los Angeles County, a juvenile justice system diversion program in which youth are judged by their peers and given restorative sentences to complete during a period of supervision. METHODS: A quasi-experimental design was used to compare youth who participated in Teen Court (n=112) to youth who participated in another diversion program administered by the Probation Department (the 654 Contract program) (n=194). Administrative data were abstracted from Probation records for all youth who participated in these programs between January 1, 2012 and June 20, 2014. Logistic and survival models were used to examine differences in recidivism - measured as whether the minor had any subsequent arrest or arrests for which the charge was filed. RESULTS: Comparison group participants had higher rates of recidivism than Teen Court participants, after controlling for age, gender, race/ethnicity, and risk level. While the magnitude of the program effects were fairly consistent across model specifications (odd ratios comparing Teen Court [referent] to school-based 654 Contract ranging from 1.95 to 3.07, hazard ratios ranging from 1.62 to 2.27), differences were not statistically significant in all scenarios. CONCLUSIONS: While this study provides modest support for the positive impact of Teen Court, additional research is needed to better understand how juvenile diversion programs can improve youth outcomes.

Public awareness of and support for infrastructure changes designed to increase walking and biking in Los Angeles County.

OBJECTIVE: Policies to promote active transportation are emerging as a best practice to increase physical activity, yet relatively little is known about public opinion on utilizing transportation funds for such investments. This study sought to assess public awareness of and support for investments in walking and biking infrastructure in Los Angeles County. METHOD: In the fall of 2013, the Los Angeles County Department of Public Health conducted a telephone survey with a random sample of registered voters in the region. The survey asked respondents to report on the presence and importance of walking and biking infrastructure in their community, travel behaviors and preferences, and demographics. RESULTS: One thousand and five interviews were completed (response rate 20%, cooperation rate 54%). The majority of participants reported walking, biking, and bus/rail transportation investments as being important. In addition, participants reported a high level of support for redirecting transportation funds to active transportation investment - the population average was 3.28 (between 'strongly' and 'somewhat' support) on a 4 point Likert scale. CONCLUSION: Voters see active transportation infrastructure as being very important and support redirecting funding to improve the infrastructure. These findings can inform policy-decisions and planning efforts in the jurisdiction.

The relationship between amount of soda consumed and intention to reduce soda consumption among adults exposed to the Choose Health LA 'Sugar Pack' health marketing campaign.

OBJECTIVE: To examine behavioural intention to reduce soda consumption after exposure to the Choose Health LA 'Sugar Pack' campaign in Los Angeles County, California, USA. DESIGN: A cross-sectional street-intercept survey was conducted to assess knowledge, attitudes, health behaviours and behavioural intentions after exposure to the 'Sugar Pack' campaign. A multivariable regression analysis was performed to examine the relationships between the amount of soda consumed and self-reported intention to reduce consumption of non-diet soda among adults who saw the campaign. SETTING: Three pre-selected Los Angeles County Metro bus shelters and/or rail stops with the highest number of 'Sugar Pack' campaign advertisement placements. SUBJECTS: Riders of the region's Metro buses and railways who were the intended audience of the campaign advertisements. RESULTS: The overall survey response rate was 56 % (resulting n 1041). Almost 60 % of respondents were exposed to the advertisements (619/1041). The multivariable logistic regression analysis suggested that the odds of reporting intention to reduce soda consumption among moderate consumers (1-6 sodas/week) were 1·95 times greater than among heavy consumers (≥1 soda/d), after controlling for clustering and covariates. Respondents with less than a high-school education and who perceived sugary beverage consumption as harmful also had higher odds; in contrast, respondents aged ≥65 years had lower odds. CONCLUSIONS: Results suggest that future campaigns should be tailored differently for moderate v. heavy consumers of soda. Similar tailoring strategies are likely needed for younger groups, for those with less educational attainment and for those who do not perceive consumption of soda as harmful.

What menu changes do restaurants make after joining a voluntary restaurant recognition program?

Programs that recognize restaurants for offering healthful options have emerged as a popular strategy to address the obesity epidemic; however, program fidelity and business responses to such programs are rarely assessed. This study sought to examine how retail restaurants in Los Angeles County chose to comply with participation criteria required by the Choose Health LA Restaurants initiative in the region; the program recognizes restaurants for offering reduced-size portions and healthy children's meals. Menus of all restaurants that joined within 1 year of program launch (n = 17 restaurant brands) were assessed for changes. Nine of the 17 brands made changes to their menus to meet participation criteria for reduced-size portions while 8 of the 10 restaurant brands that offered children's menus made changes to improve the healthfulness of children's meals. Results of this comparative assessment lend support to restaurant compliance with program criteria and menu improvements, even though they are voluntary, representing an important step toward implementing this strategy in the retail environment.

Assessing the connection between health and education: identifying potential leverage points for public health to improve school attendance.

OBJECTIVES: We examined multiple variables influencing school truancy to identify potential leverage points to improve school attendance. METHODS: A cross-sectional observational design was used to analyze inner-city data collected in Los Angeles County, California, during 2010 to 2011. We constructed an ordinal logistic regression model with cluster robust standard errors to examine the association between truancy and various covariates. RESULTS: The sample was predominantly Hispanic (84.3%). Multivariable analysis revealed greater truancy among students (1) with mild (adjusted odds ratio [AOR] = 1.57; 95% confidence interval [CI] = 1.22, 2.01) and severe (AOR = 1.80; 95% CI = 1.04, 3.13) depression (referent: no depression), (2) whose parents were neglectful (AOR = 2.21; 95% CI = 1.21, 4.03) or indulgent (AOR = 1.71; 95% CI = 1.04, 2.82; referent: authoritative parents), (3) who perceived less support from classes, teachers, and other students regarding college preparation (AOR = 0.87; 95% CI = 0.81, 0.95), (4) who had low grade point averages (AOR = 2.34; 95% CI = 1.49, 4.38), and (5) who reported using alcohol (AOR = 3.47; 95% CI = 2.34, 5.14) or marijuana (AOR = 1.59; 95% CI = 1.06, 2.38) during the past month. CONCLUSIONS: Study findings suggest depression, substance use, and parental engagement as potential leverage points for public health to intervene to improve school attendance.

Student receptivity to new school meal offerings: assessing fruit and vegetable waste among middle school students in the Los Angeles Unified School District.

OBJECTIVE: We sought to characterize student receptivity to new menu offerings in the Los Angeles Unified School District by measuring the levels of fruit and vegetable waste after implementation of changes to the school lunch menu in fall 2011. METHODS: We measured waste at four randomly selected middle schools in the school district, using two sources: a) food prepared and left over after service (production waste); and b) food that was selected but not eaten by students (plate waste). RESULTS: 10.2% of fruit and 28.7% of vegetable items prepared at the four schools were left over after service. Plate waste data, collected from 2228 students, suggest that many of them did not select fruit (31.5%) or vegetable (39.6%) items. Among students who did, many threw fruit and vegetable items away without eating a single bite. CONCLUSIONS: Our findings suggest that fruit and vegetable waste was substantial and that additional work may be needed to increase student selection and consumption of fruit and vegetable offerings. Complementary interventions to increase the appeal of fruit and vegetable options may be needed to encourage student receptivity to these healthier items in the school meal program.

The "sugar pack" health marketing campaign in Los Angeles County, 2011-2012.

As part of a comprehensive approach to combating the obesity epidemic, the Los Angeles County Department of Public Health launched the "Sugar Pack" health marketing campaign in fall 2011. Carried out in three stages, the campaign sought to educate and motivate the public to reduce excess calorie intake from sugar-sweetened beverage consumption. The primary Sugar Pack creative concepts provided consumers with information about the number of sugar packs contained in sugary drinks. Data from formative market research as well as lessons from previous campaigns in other U.S. jurisdictions informed the development of the materials. These materials were disseminated through a multipronged platform that included paid outdoor media on transit and billboards and messaging using social media (i.e., Twitter, Facebook, YouTube, and sendable e-cards). Initial findings from a postcampaign assessment indicate that the Sugar Pack campaign reached broadly into targeted communities, resulting in more than 515 million impressions. Lessons learned from the campaign suggest that employing health marketing to engage the public can lead to increased knowledge, favorable recognition of health messages, and self-reported intention to reduce sugar-sweetened beverage consumption, potentially complementing other obesity prevention strategies in the field.

Integrating sodium reduction strategies in the procurement process and contracting of food venues in the County of Los Angeles government, 2010-2012.

Since sodium is ubiquitous in the food supply, recent approaches to sodium reduction have focused on increasing the availability of lower-sodium products through system-level and environmental changes. This article reviews integrated efforts by the Los Angeles County Sodium Reduction Initiative to implement these strategies at food venues in the County of Los Angeles government. The review used mixed methods, including a scan of the literature, key informant interviews, and lessons learned during 2010-2012 to assess program progress. Leveraging technical expertise and shared resources, the initiative strategically incorporated sodium reduction strategies into the overall work plan of a multipartnership food procurement program in Los Angeles County. To date, 3 County departments have incorporated new or updated nutrition requirements that included sodium limits and other strategies. The strategic coupling of sodium reduction to food procurement and general health promotion allowed for simultaneous advancement and acceleration of the County's sodium reduction agenda.

"Health in All Policies": taking stock of emerging practices to incorporate health in decision making in the United States.

OBJECTIVE: Policies affecting the determinants of health lie largely outside the control of the health care and public health sectors. Ensuring health considerations in the formation and implementation of policies, programs, projects, and plans from all sectors, though lofty, is the overall aim of Health in All Policies. The purpose of this article was to identify categories of strategies that illustrate how Health in All Policies had been implemented in the United States. DESIGN: We used a 3-phased process: (1) review of the published and gray literature; (2) analysis of case examples to identify a draft framework, which included tactics and strategies for implementing Health in All Policies; and (3) vetting the draft framework through individual and group consultation. RESULTS: We identify 7 interrelated strategies for incorporating health considerations into decisions and systems: (1) developing and structuring cross-sector relationships; (2) incorporating health into decision-making processes; (3) enhancing workforce capacity; (4) coordinating funding and investments; (5) integrating research, evaluation and data systems; (6) synchronizing communications and messaging; and (7) implementing accountability structures. For each strategy, we provide illustrative examples from the United States to help public health leaders identify effective tactics for Health in All Policies implementation. CONCLUSIONS: Through our review, we offer a starting point for categorizing and describing the emerging practices used to work across sectors and address the determinants of health. By delineating the different types of strategies and tactics to achieve Health in All Policies, we provide public health practitioners with a "menu" of options for incorporating Health in All Policies into their work.

Barriers and facilitators to implementing primary stroke center policy in the United States: results from 4 case study states.

OBJECTIVES: We identified barriers and facilitators to the state-level implementation of primary stroke center (PSC) policies, which encourage the certification or designation of specialized stroke treatment facilities and may address concerns such as transportation bypass, telemedicine, and treatment protocols. METHODS: We studied the experiences of 4 states (Florida, Massachusetts, New Mexico, and New York) selected from the 18 states that had enacted PSC policies or were actively considering doing so. We conducted semistructured interviews during fieldwork in each case study state. RESULTS: Our results showed that system fragmentation, gaps in human and financial resources, and complexity at the interorganizational and operational levels are common barriers and that policy champions, stakeholder support and communication, and operational adaptation are essential facilitators in the adoption and implementation of PSC policies. CONCLUSIONS: The identification of barriers and facilitators reveals the contextual elements that can help or hinder policy implementation and may be useful in informing policy formulation and implementation in other jurisdictions. Proactively identifying jurisdictional challenges and opportunities may help facilitate the policy process for PSC designation and allow jurisdictions to develop more effective stroke systems of care.

Estimating the potential health impact and costs of implementing a local policy for food procurement to reduce the consumption of sodium in the county of Los Angeles.

OBJECTIVES: We examined approaches to reduce sodium content of food served in settings operated or funded by the government of the County of Los Angeles, California. METHODS: We adapted health impact assessment methods to mathematically simulate various levels of reduction in the sodium content of food served by the County of Los Angeles and to estimate the reductions' potential impacts on mean systolic blood pressure (SBP) among food-service customers. We used data provided by county government food-service vendors to generate these simulations. RESULTS: Our analysis predicted that if the postulated sodium-reduction strategies were implemented, adults would consume, on average, 233 fewer milligrams of sodium each day. This would correspond to an average decrease of 0.71 millimeters of mercury in SBP among adult hypertensives, 388 fewer cases of uncontrolled hypertension in the study population, and an annual decrease of $629,724 in direct health care costs. CONCLUSIONS: Our findings suggest that a food-procurement policy can contribute to positive health and economic effects at the local level. Our approach may serve as an example of sodium-reduction analysis for other jurisdictions to follow.