Effectiveness of implementing evidence-based approaches to promote physical activity in a Midwestern micropolitan area using a quasi-experimental hybrid type I study design.

BACKGROUND: Much evidence-based physical activity (PA) interventions have been tested and implemented in urban contexts. However, studies that adapt, implement, and evaluate the effectiveness of these interventions in micropolitan rural contexts are needed. The study aimed to evaluate the effectiveness of the Active Ottumwa intervention to promote PA in a micropolitan community. METHODS: Between 2013 - 2019, we implemented Active Ottumwa in a micropolitan setting, and subsequently implemented and evaluated its effectiveness using a Hybrid Type I design. In this paper, we describe the intervention's effectiveness in promoting PA. We collected PA data over 24 months from a cohort of community residents using accelerometers and PA data from two cross-sectional community surveys administered in 2013 and 2018, using the Global Physical Activity Questionnaire. RESULTS: From the cohort, we found significant change in PA over 24 months (P = 0.03) corresponding to a 45-min daily decrease in sedentary activity, a daily increase of 35-min in light PA and 9 min in moderate-to-vigorous PA. There was a statistically significant (P = 0.01) increasing trend at the population-level in the moderate-to-vigorous composition of 7 min between the two cross-sectional assessments (95% CI: 0.1%-1.34%). CONCLUSIONS: The study demonstrates that the adapted evidence-based PA interventions in a micropolitan context is effective.

Outcomes Associated With Rural Emergency Department Provider-to-Provider Telehealth for Sepsis Care: A Multicenter Cohort Study.

STUDY OBJECTIVE: To test the hypothesis that provider-to-provider tele-emergency department care is associated with more 28-day hospital-free days and improved Surviving Sepsis Campaign (SSC) guideline adherence in rural emergency departments (EDs). METHODS: Multicenter (n=23), propensity-matched, cohort study using medical records of patients with sepsis from rural hospitals in an established, on-demand, rural video tele-ED network in the upper Midwest between August 2016 and June 2019. The primary outcome was 28-day hospital-free days, with secondary outcomes of 28-day inhospital mortality and SSC guideline adherence. RESULTS: A total of 1,191 patients were included in the analysis, with tele-ED used for 326 (27%). Tele-ED cases were more likely to be transferred to another hospital (88% versus 8%, difference 79%, 95% confidence interval [CI] 75% to 83%). After matching and regression adjustment, tele-ED cases did not have more 28-day hospital-free days (difference 0.07 days more for tele-ED, 95% CI -0.04 to 0.17) or 28-day inhospital mortality (adjusted odds ratio [aOR] 0.51, 95% CI 0.16 to 1.60). Adherence with both the SSC 3-hour bundle (aOR 0.59, 95% CI 0.28 to 1.22) and complete bundle (aOR 0.45, 95% CI 0.02 to 11.60) were similar. An a priori-defined subgroup of patients treated by advanced practice providers suggested that the mortality was lower in the cohort with tele-ED use (aOR 0.11, 95% CI 0.02 to 0.73) despite no significant difference in complete SSC bundle adherence (aOR 2.88, 95% CI 0.52 to 15.86). CONCLUSION: Rural emergency department patients treated with provider-to-provider tele-ED care in a mature network appear to have similar clinical outcomes to those treated without.

TELEmedicine as an intervention for sepsis in emergency departments: a multicenter, comparative effectiveness study (TELEvISED Study).

Sepsis is a life-threatening infection that affects over 1.7 million Americans annually. Low-volume rural hospitals have worse sepsis outcomes, and emergency department (ED)-based telemedicine (tele-ED) has been one promising strategy for improving rural sepsis care. The objective of this study is to evaluate the impact of tele-ED consultation on sepsis care and outcomes in rural ED patients. The TELEvISED study is a multicenter (n = 25) retrospective propensity-matched comparative effectiveness study of tele-ED care for rural sepsis patients in a mature tele-ED network. Telemedicine-exposed patients will be matched with non telemedicine patients using a propensity score to predict tele-ED use. The primary outcome is 28-day hospital free days, and secondary outcomes include adherence with guidelines, mortality and organ failure. ClinicalTrials.gov: NCT04441944.

Building Leadership, Capacity, and Power to Advance Health Equity and Justice through Community-Engaged Research in the Midwest.

The Health Equity Advancement Lab (HEAL) at the University of Iowa College of Public Health began in 2012 to support students, researchers, and community members interested in tackling persistent health inequities through a community-based participatory research (CBPR) approach. Using concepts from critical consciousness theory, we developed an approach to building students', faculty members', and community partners' capacity to engage in CBPR to promote health equity that involved immersion in developing CBPR projects. Our paper describes the evolution of HEAL as a facilitating structure that provides a support network and engages diverse stakeholders in critical reflection as they participate in research to advance health equity, and resulting political efficacy and social action. We describe one HEAL-affiliated research project that employs a CBPR approach and has a strong focus on providing transformative learning experiences for students, faculty, and community members. We highlight challenges, successes, and lessons learned in the application of critical consciousness as a framework that engages diverse academic and community partners seeking to promote health equity. We argue that critical consciousness is a relevant theoretical framework to promote transformative learning among students, faculty, and community partners to promote health equity research in diverse communities.

Implementing Community-Based Participatory Research with Communities Affected by Humanitarian Crises: The Potential to Recalibrate Equity and Power in Vulnerable Contexts.

Worldwide, over 70.8 million people are forcibly displaced from their homes as a result of persecution, conflict, violence, or human rights violation. In humanitarian crises, protection and the provision of basic needs are often prioritized. Research may be seen as opportunistic. However, without documenting and researching humanitarian responses, knowledge is not shared and does not accumulate, limiting the application of evidence-based interventions where they are most needed. Research in humanitarian crises is complex, both ethically and methodologically. Community-engaged research, and specifically community-based participatory research (CBPR), can address some of the challenges of research in these settings. Using case studies of research we have conducted with communities affected by humanitarian crises, we highlight challenges and opportunities of the application of the ten core principles of CBPR in humanitarian settings. Despite some challenges and barriers, CBPR is a highly effective approach to use when engaging these populations in research. We argue that the application of CBPR in these settings has the potential to recalibrate the scales of equity and power among vulnerable populations.

The Interaction of Dopamine Genes and Financial Stressors to Predict Adulthood Intimate Partner Violence Perpetration.

Three dopamine genes (DAT1, DRD2, and DRD4) have been associated with interpersonal delinquency, aggression, and violence when individuals experience adverse environmental exposures. Guided by the catalyst model of aggression, risk alleles identified in previous studies were hypothesized to be associated with intimate partner violence (IPV) perpetration in the presence of financial stressors, a possible environmental trigger. This hypothesis was tested using weighted, clustered logistic regression with data from the National Longitudinal Study of Adolescent to Adult Health. The direct effects DAT1, DRD2, and DRD4 on IPV perpetration, and the interaction of DAT1, DRD2, and DRD4 and financial stressors on IPV perpetration were assessed. Due to cell size, only White men and women were included in this analysis. Increasing number of financial stressors was associated with increased odds of IPV perpetration, regardless of DAT1, DRD2, and DRD4 alleles. As predicted, increasing number of financial stressors was more strongly associated with IPV perpetration among individuals with high-risk DAT1 alleles, than individuals with low-risk alleles. However, this relationship was inverted for DRD2. Although there was still a significant interaction between DRD2 and financial stressors, individuals with low-risk alleles had higher odds of IPV perpetration in the presence of financial stressors. A similar, nonsignificant relationship was found for DRD4. These findings indicate that these genes may interact differently with environmental exposures and types of violent behavior. In addition, the findings may, if replicated, suggest dopamine plays a different role in IPV perpetration compared with other forms of aggression and violence.

Assessing the national capacity for disaster research response (DR2) within the NIEHS Environmental Health Sciences Core Centers.

INTRODUCTION: Disaster research response (DR2) is necessary to answer scientific questions about the environmental health impacts of disasters and the effectiveness of response and recovery strategies. This research explores the preparedness and capacity of National Institute of Environmental Health Sciences (NIEHS) P30 Core Centers (CCs) to conduct DR2 and engage with communities in the context of disasters. METHODS: In early 2018, we conducted an online survey of CC Directors (n = 16, 69.5% response rate) to identify their DR2 relevant scientific assets, capabilities, and activities. Summary statistics were calculated. We also conducted in-depth, semi-structured interviews with 16 (69.5%) CC Community Engagement Core directors to identify facilitators and barriers of DR2 community engagement. Interview notes were coded and thematically analyzed. RESULTS: Survey: While 56% of responding CCs reported prior participation in DR2 and preparedness to repurpose funding to support DR2, less than one third reported development of a disaster-specific data collection protocol, deployment plan, or concept of operations plan, participation in an exercise to test DR2 capacity, development of academic partnerships to conduct DR2, development of a process for fast-tracking institutional review board approvals for DR2, or maintenance of formal agreements with state, local, or community-based partner(s). A number of CCs reported developing or considering developing capacity in these areas. Barriers to, and tools and resources to enhance, CC engagement in DR2 were identified. Interviews: Four key components for community engaged DR2 were identified: pre-existing community relationships, responsive research that benefits communities, coordination among researchers, and coordination with community response partners. Several roles for, benefits of, and barriers to Community Engagement Rapid Response Teams (CERRT) were described. CONCLUSIONS: CCs have significant scientific assets and community partnerships that can be leveraged for DR2; however, additional planning is necessary to ensure that these scientific assets and community partnerships are leveraged when disasters strike.

Establishing a Community-Based Participatory Research Partnership in a Rural Community in the Midwest.

BACKGROUND: Rural health disparities are well-documented. "New destination" communities in predominantly rural states have emerged in recent years, with immigrants moving into these communities for better opportunities. Few reports of community-based participatory partnerships with these communities have been previously described in the literature. OBJECTIVES: We report on the formation and implementation of a community-academic partnership to reduce health disparities in a rural Midwestern community. METHODS: We describe the creation of a partnership between the University of Iowa (UI) Prevention Research Center (PRC) and the Ottumwa, Iowa community. RESULTS: We describe the partnership formation, activities, and results of the implementation of the partnership, and challenges encountered, including balancing attention to different health disparities populations and ensuring mechanisms for hearing from the different voices in the community. CONCLUSIONS: Our experience suggests the importance and challenge of considering the multiple dimensions of health disparities in rural new destination Midwestern communities.

Associations Between Organizational Culture, Workplace Health Climate, and Employee Smoking at Smaller Workplaces.

BACKGROUND: Smaller workplaces frequently employ low-wage earners, who have higher smoking rates. Organizational culture and workplace health climate are two characteristics that could influence employee smoking. The purpose of this study was to examine the associations between organizational culture, workplace health climate, and smoking among employees at small (20-99 employees) and very small (<20 employees) workplaces. We proposed the following hypotheses: a stronger clan culture will be associated with a better workplace health climate (HP1); a better workplace health climate will be associated with lower odds of current smoking (HP2); and there will be an association between workplace health climate and smoking intensity (HP3) and between workplace health climate and quit intention (HP4). METHODS: Executives and employees completed separate online questionnaires. Data collection occurred between June and October 2017. We used regression and Fisher's exact tests to answer study hypotheses. RESULTS: Workplaces with stronger clan cultures had a better workplace health climate (b = 0.27, P < .05), providing support for HP1. A better workplace health climate was associated with lower odds of being a current smoker (odds ratio [OR] = 0.08; 95% confidence interval [CI]: 0.01, 0.53), providing support for HP2. No significant relationship existed between workplace health climate and smoking intensity (P = .50) or between workplace health climate and intention to quit smoking (P = .32); therefore, HP3 and HP4 were not supported. CONCLUSION: Certain culture types may inform an organization's health climate. Despite a lower likelihood of current smoking in workplaces with better health climates, a better health climate may not be sufficient to produce changes in smoking behavior and intentions.

A qualitative assessment of the smoking policies and cessation activities at smaller workplaces.

BACKGROUND: To reduce the negative consequences of smoking, workplaces have adopted and implemented anti-smoking initiatives. Compared to large workplaces, less research exists about these initiatives at smaller workplaces, which are more likely to hire low-wage workers with higher rates of smoking. The purpose of this study was to describe and compare the smoking policies and smoking cessation activities at small (20-99 employees) and very small (< 20 employees) workplaces. METHODS: Thirty-two key informants coming from small and very small workplaces in Iowa completed qualitative telephone interviews. Data collection occurred between October 2016 and February 2017. Participants gave descriptions of the anti-smoking initiatives at their workplace. Additional interview topics included questions on enforcement, reasons for adoption, and barriers and facilitators to adoption and implementation. The data were analyzed using counts and content and thematic analysis. RESULTS: Workplace smoking policies were nearly universal (n = 31, 97%), and most workplaces (n = 21, 66%) offered activities to help employees quit smoking. Reasons for adoption included the Iowa Smokefree Air Act, to improve employee health, and organizational benefits (e.g., reduced insurance costs). Few challenges existed to adoption and implementation. Commonly cited facilitators included the Iowa Smokefree Air Act, no issues with compliance, and support from others. Compared to small workplaces, very small workplaces offered cessation activities less often and had fewer tobacco policy restrictions. CONCLUSIONS: This study showed well-established tobacco control efforts in small workplaces, but very small workplaces lagged behind. To reduce potential health disparities in smoking, future research and intervention efforts in tobacco control should focus on very small workplaces.

Active Ottumwa: Adapting Evidence-Based Recommendations to Promote Physical Activity in a Micropolitan New Destination Community.

Background: Evidence-based interventions have been developed and tested to promote physical activity, but fewer studies have focused on identifying effective intervention strategies for mid-size rural communities, especially new immigrant destinations. We report here on the design and implementation of Active Ottumwa, a community-wide intervention using a lay health advisor approach to increase physical activity in a micropolitan new destination community in the rural state of Iowa. Methods: The Active Ottumwa study is part of a community-academic partnership in Ottumwa, IA. Evidence-based strategies recommended by the Community Guide for Preventive Services guided study implementation and included behavioral and social, campaign and informational, and environmental and policy approaches. Evaluation methods for this study are multi-faceted and include a cross-sectional community survey, longitudinal cohort assessment, observational data, key informant interviews, and project records. Results: We are currently in our second year of intervention implementation, with 45 lay health advisors (termed physical activity leaders here) trained to carry out behavioral and social intervention approaches, including walking groups, tai chi, and yoga. We have completed a communication and informational campaign utilizing five channels. Our longitudinal cohort has been recruited, with baseline and 12-month data collection completed. Conclusions: This study will assess the effectiveness and impact of a community-wide intervention to support physical activity.

Organizational culture and the adoption of anti-smoking initiatives at small to very small workplaces: An organizational level analysis.

INTRODUCTION: Many workplaces have adopted anti-smoking initiatives to reduce smoking behavior, but small workplaces are less likely to adopt these initiatives. One factor that could influence adoption is organizational culture, defined as the values and assumptions shared by members of an organization. The aim of this study was to examine the types of organizational culture associated with smoking policy strength and adoption of smoking cessation activities at small (20-99 employees) and very small (<20 employees) workplaces. Two study hypotheses were made: An increase in clan culture (characterized by participation in decision-making and human resources development) will be associated with an increase in smoking policy strength (H1) and higher odds of having cessation activities in the workplace (H2). METHODS: Between June and October 2017, executives and employees coming from small and very small workplaces participated in separate surveys. Executives answered questions about their workplace's anti-smoking initiatives, while employees completed a 12-item questionnaire about organizational culture. We aggregated employee data to perform linear and logistic regression at the organizational level. RESULTS: Organizational culture was not significantly associated with smoking policy strength, therefore H1 was not supported. Counter to H2, an increase in clan culture was associated with lower odds of offering smoking cessation activities (OR=0.06; 95% CI: 0.01-0.58). CONCLUSIONS: We did not find support for the hypothesized relationships. External factors and additional cultural characteristics may explain study findings. Continued research on culture and ways to improve tobacco control within smaller workplaces is needed.

Respondent-Driven Sampling to Recruit Latinos in a Midwest Micropolitan Area: Lessons Learned and Recommendations for Translational Work.

INTRODUCTION: Latinos constitute a hard-to-reach minority population in Iowa. METHODS: We used respondent-driven sampling (RDS) to supplement random digit dialing (RDD) to recruit Latinos for a community physical activity intervention. RESULTS: RDS yielded a 59% increase in Latino participation in just two months, with few demographic differences between RDS and RDD groups. CONCLUSIONS: RDS may increase recruitment of underrepresented populations and strengthen community engagement; however, it is not a quick fix for underperforming recruitment methods.

Factors Inhibiting Physical Activity as Treatment for Diabetic Chuukese in Chuuk and Hawai'i.

Type 2 diabetes is epidemic in the US Pacific. Developing culturally sensitive physical activities and anti-sedentary interventions may reduce morbidity and mortality associated with type 2 diabetes. The purpose of the study was to identify sedentary and physical activity factors related to diabetes prevention and control among Chuukese living in Chuuk and Hawai'i. This study utilized grounded theory to identify socio-cultural influences that hinder or facilitate adherence to physical activity recommendations. Data was gathered through focus group discussions with individuals with diabetes and their caretakers. Findings include in-depth and detailed information on five different types of sedentary behaviors (purposeful sitting, lazy sitting, wasting time, resting and recreation sitting, and no-can move) and environmental factors that influenced participants' sedentary behaviors and physical activity. These findings underscore the need for physical activity and anti-sedentary interventions that are purposeful, collectivistic, age and gender appropriate and church based.

Community airborne particulate matter from mining for sand used as hydraulic fracturing proppant.

Field and laboratory studies were conducted to evaluate the impact of proppant sand mining and processing activities on community particulate matter (PM) concentrations. In field studies outside 17 homes within 800m of sand mining activities (mining, processing, and transport), respirable (PM4) crystalline silica concentrations were low (<0.4µg/m3) with crystalline silica detected on 7 samples (2% to 4% of mass). In long-term monitoring at 6 homes within 800m of sand mining activities, the highest daily mean PM concentrations observed were 14.5µg/m3 for PM2.5 and 37.3µg/m3 for PM10, although infrequent (<3% of time), short-term elevated PM concentrations occurred when wind blew over the facility. In laboratory studies, aerosolized sand was shown to produce respirable-sized particles, containing 6% to 19% crystalline silica. Dispersion modeling of a mine and processing facility indicated that PM10 can exceed standards short distances (<40m) beyond property lines. Lastly, fence-line PM and crystalline silica concentrations reported to state agencies were substantially below regulatory or guideline values, although several excursions were observed for PM10 when winds blew over the facility. Taken together, community exposures to airborne particulate matter from proppant sand mining activities at sites similar to these appear to be unlikely to cause chronic adverse health conditions.

Factors Influencing Diabetes Self-Management Among Medically Underserved Patients With Type II Diabetes.

In this study, researchers compare and contrast issues regarding diabetes self-management between persons in good versus poor glycemic control. The sample comprises low-income racially diverse adults with diabetes from four mid-western community health centers; 44 patients participated in eight focus groups divided by control status (HbA1c of > 9 [uncontrolled] or < 7 [controlled]). Themes common to both groups included the impact of dietary restrictions on social interactions, food cravings, the impact of mental health on self-management, and the importance of formal and informal (friends and family) support. Those in the uncontrolled groups described fear about being able to control their diabetes, confusion about self-management, and difficulty managing their diabetes while caring for family members. Although those in the controlled groups acknowledged difficulties, they discussed resisting cravings, making improvements with small changes, positive feelings about their ability to control their diabetes, and enjoying new foods and exercise. Interventions should include mental health support, incorporate formal and informal patient support structures, and address literacy issues. Health care providers and intervention personnel should be very concrete about how to do self-management tasks and guide patients on how to alter their diabetes regimens for social and other important life events.

Interactions of adolescent social experiences and dopamine genes to predict physical intimate partner violence perpetration.

OBJECTIVES: We examined the interactions between three dopamine gene alleles (DAT1, DRD2, DRD4) previously associated with violent behavior and two components of the adolescent environment (exposure to violence, school social environment) to predict adulthood physical intimate partner violence (IPV) perpetration among white men and women. METHODS: We used data from Wave IV of the National Longitudinal Study of Adolescent to Adult Health, a cohort study following individuals from adolescence to adulthood. Based on the prior literature, we categorized participants as at risk for each of the three dopamine genes using this coding scheme: two 10-R alleles for DAT1; at least one A-1 allele for DRD2; at least one 7-R or 8-R allele for DRD4. Adolescent exposure to violence and school social environment was measured in 1994 and 1995 when participants were in high school or middle school. Intimate partner violence perpetration was measured in 2008 when participants were 24 to 32 years old. We used simple and multivariable logistic regression models, including interactions of genes and the adolescent environments for the analysis. RESULTS: Presence of risk alleles was not independently associated with IPV perpetration but increasing exposure to violence and disconnection from the school social environment was associated with physical IPV perpetration. The effects of these adolescent experiences on physical IPV perpetration varied by dopamine risk allele status. Among individuals with non-risk dopamine alleles, increased exposure to violence during adolescence and perception of disconnection from the school environment were significantly associated with increased odds of physical IPV perpetration, but individuals with high risk alleles, overall, did not experience the same increase. CONCLUSION: Our results suggested the effects of adolescent environment on adulthood physical IPV perpetration varied by genetic factors. This analysis did not find a direct link between risk alleles and violence, but contributes to growing research indicating that if genetic factors contribute to perpetration, this relationship is likely complicated and the result of interactions with other factors.

Associations of financial stressors and physical intimate partner violence perpetration.

BACKGROUND: Contextual factors, such as exposure to stressors, may be antecedents to IPV perpetration. These contextual factors may be amenable to modification through intervention and prevention. However, few studies have examined specific contextual factors. To begin to address this gap, we examined the associations between financial stressors and three types of physical IPV perpetration. METHODS: This analysis used data from Wave IV of The National Longitudinal Study of Adolescent to Adult Health. We used logistic regression to examine the associations of financial stressors and each type of IPV (minor, severe, causing injury), and multinomial logit regression to examine the associations of financial stressors and patterns of co-occurring types of IPV perpetration (only minor; only severe; minor and severe; minor, severe, and causing injury; compared with no perpetration). RESULTS: Fewer men perpetrated threats/minor physical IPV (6.7 %) or severe physical IPV (3.4 %) compared with women (11.4 % and 8.8 %, respectively). However, among physical IPV perpetrators, a higher percentage of men (32.0 %) than women (21.0 %) reported their partner was injured as a result of the IPV. In logistic regression models of each type of IPV perpetration, both the number of stressors experienced and several types of financial stressors were associated with perpetrating each type of IPV. Utilities nonpayment, housing nonpayment, food insecurity, and no phone service were associated with increased odds of perpetrating each form of IPV in adjusted analysis. Eviction was associated with perpetrating severe physical IPV but not threats/minor IPV or IPV causing injury. In multinomial logit regression comparing patterns of IPV perpetration to perpetrating no physical IPV, the relationships of financial stressors were less consistent. Food insecurity was associated with perpetrating only minor physical IPV. Comparatively, overall number of financial stressors and four types of financial stressors (utilities nonpayment, housing nonpayment, food insecurity, and disconnected phone service) were associated with perpetrating all three forms of physical IPV. CONCLUSIONS: Combined with prior research, our results suggested interventions to improve financial well-being may be a novel way to reduce physical IPV perpetration.