Providing doula support to publicly insured women in central Texas: A financial cost-benefit analysis.

BACKGROUND: Disparities in birth outcomes continue to exist in the United States, particularly for low-income, publicly insured women. Doula support has been shown to be a cost-effective intervention in predominantly middle-to-upper income White populations, and across all publicly insured women at the state level. This analysis extends previous studies by providing an estimate of benefits that incorporates variations in averted outcomes by race and ethnicity in the context of one region in Texas. The objectives of this study were to determine (1) whether the financial value of benefits provided by doula support exceeds the costs of delivering it; (2) whether the cost-benefit ratio differs by race and ethnicity; and (3) how different doula reimbursement levels affect the cost-benefit results with respect to pregnant people covered by Medicaid in central Texas. METHODS: We conducted a forward-looking cost-benefit analysis using secondary data carried out over a short-term time horizon taking a public payer perspective. We focused on a narrow set of health outcomes (preterm delivery and cesarean delivery) that was relatively straightforward to monetize. The current, usual care state was used as the comparison condition. RESULTS: Providing pregnant people covered by Texas Medicaid with access to doulas during their pregnancies was cost-beneficial (benefit-to-cost ratio: 1.15) in the base model, and 65.7% of the time in probabilistic sensitivity analyses covering a feasible range of parameters. The intervention is most cost-beneficial for Black women. Reimbursing doulas at $869 per client or more yielded costs that were greater than benefits, holding other parameters constant. CONCLUSIONS: Expanding Medicaid pregnancy-related coverage to include doula services would be cost-beneficial and improve health equity in Texas.

Health Care Use, Coverage, and Experiences During the Year Prior to Pregnancy in a Primarily Hispanic Population with Low Income: A Descriptive Qualitative Study.

INTRODUCTION: A qualitative picture of the health care experiences prior to pregnancy can inform patient-centered strategies to optimize preconception health. This study describes health care utilization and experiences and how health care costs were covered in the year prior to pregnancy in a population of primarily Hispanic women with low income. METHODS: Pregnant participants were recruited from 5 Federally Qualified Health Center clinics. Semistructured interviews included questions about health care in the year prior to pregnancy. Transcripts were analyzed using a thematic approach that integrated deductive and inductive analysis. RESULTS: Most participants self-identified as Hispanic. Just under half were US citizens. All but one were Medicaid or Children's Health Insurance Program Perinatal coverage insurance during pregnancy and relied on a variety of strategies to cover prepregnancy health care costs. Almost all received health care during the year prior to pregnancy. Fewer than half reported an annual preventive visit. Health care needs that led to care-seeking included a prior pregnancy, chronic depression, contraception, workplace injury, a persistent rash, screening and treatment for sexually transmitted infection, breast pain, stomach pain (leading to gallbladder removal), and kidney infection. The ways in which study participants covered the costs of health care ranged in terms of sources and complexity. Although some participants described stable health care coverage, most reported changes throughout the year as they pieced together various health care coverage programs and out-of-pocket payments. When participants did seek health care prior to their current pregnancy, most described the experience in positive terms and focused on health care provider communication quality. Respect of patient autonomy was highly valued. DISCUSSION: Women with pregnancy-related health care coverage accessed care for a wide range of health care needs prior to pregnancy. Health care providers may consider strategies to respectfully introduce preconception care into any visit by an individual who could become pregnant.

Qualitative Research to Describe Food Bank-Health Care Partnerships: What Types of Models are Currently Being Used to Facilitate Food Bank-Health Care Partnerships in Texas?

BACKGROUND: Food banks and health care are being increasingly called on to partner together to support individuals and families experiencing food insecurity, yet few published works highlight descriptions of current food bank-health care partnerships. OBJECTIVE: The aim of this study was to identify and describe food bank-health care partnerships, the impetus for development of partnerships, and challenges to sustainable partnerships within a single-state area. DESIGN: Qualitative data collection using semi-structured interviews was performed. PARTICIPANTS: Twenty-seven interviews were completed with representatives of all 21 food banks in Texas. All interviews were between 45 and 75 minutes and completed virtually using Zoom. MAIN OUTCOME MEASURE: Types of models used for implementation, impetus for partnership development, and challenges to partnership sustainability were identified through interview questions. STATISTICAL ANALYSIS PREFORMED: Content analysis was performed in NVivo (Lumivero. Denver, CO), using transcriptions from voice-recorded semi-structured interviews. RESULTS: Four types of models of current food bank-health care partnerships were identified; they included food insecurity screening and referral, emergency food distribution at or near health care partner, pop-up food distribution and health screenings in community settings, and specialty programs for patients referred by health care. The impetus for partnership formation most often came from pressures from Feeding America or the belief that partnerships provided an opportunity to reach individuals and families that were currently not being served by the food bank. Challenges to sustainable partnership included lack of investment in both physical capacity and staff, administrative burden, and poorly developed referral processes for partnership programs. CONCLUSION: Food bank-health care partnerships are forming in diverse communities and settings, yet they need significant capacity building to support sustainable implementation and future growth.

Implementing food bank and healthcare partnerships: a pilot study of perspectives from charitable food systems in Texas.

BACKGROUND: Partnerships between charitable food systems and healthcare systems have been forming across the country to support individuals and families experiencing food insecurity, yet little research has focused on these partnerships, particularly from a food bank perspective. The objective of this exploratory pilot study was to identify implementation challenges and facilitators of charitable food system and healthcare partnerships from the food bank perspective. METHOD: Texas food banks with existing food bank/healthcare partnerships were identify through website review and support from Feeding Texas. Interview questions were tailored to each interview, but all focused on identify program components of the food bank/healthcare partnership and implementation barriers/facilitators of the partnership. In total, six interviews were conducted with food bank/healthcare partnership leaders (n = 4) and charitable food system experts (n = 2) about their experiences of working with food bank/healthcare partnerships. All interviews were completed via Zoom and took between 30 and 60 min to completed. Detailed notes were taking during each interview, and immediately discussed with the complete research time to formulate broad implementation themes. RESULTS: Interviews suggest unique implementation challenges exist at all levels of food bank/healthcare partnerships including the partnership, program, and system levels. Partnership-level implementation challenges focused on issues of partnership scale and data collection, sharing, and analysis. Program-level implementation challenges focused on food and produce expectations. Structural-level implementation challenges included issues of food safety, subsidized food regulations, and patient privacy. Implementation facilitators included leadership support, mission compatibility/organizational readiness, food insecurity training, and identify of partnership champions. CONCLUSIONS: This study adds to the growing interest in food bank/healthcare partnership as it highlights unique implementation challenges and facilitators for cross-sector partnerships between healthcare systems and community-based charitable food systems. Ultimately, we believe that collaborative discussion among leaders of charitable food systems and healthcare systems is needed to overcome outlined implementation challenges to better facilitate sustainable, equitable implementation of food bank/healthcare partnerships.

Experiences and Perspectives on Adopting New Practices for Social Needs-targeted Care in Safety-net Settings: A Qualitative Case Series Study.

INTRODUCTION: Clinical settings are being encouraged to identify and address patients' social needs within the clinic or through partner organizations. The purpose of this qualitative study was to describe the current practice of social needs-targeted care in 3 Texas safety net clinics, and facilitators and barriers to adopting new social needs-targeted care tools and practices. METHODS: Interviews were conducted with staff at 3 safety net clinics serving small and mid-sized communities. Analysis focused on perspectives and decisions around adopting new tools or practices related to social needs-targeted care, including standardized screening tools and community resource referral platforms. RESULTS: Nine staff across 3 organizations were interviewed. Two organizations were currently using a standard social needs screening tool in their routine practice, and a third was considering doing so. One organization had adopted a community resource referral platform in partnership with a large community collaboration. Three case studies illustrate a range of facilitators, barriers, perceived benefits, and drawbacks influencing social needs-targeted practices. Benefits of systematic data collection on social needs included the generation of data for community action. Drawbacks include concerns about data privacy. Community resource referral platforms were seen as valuable for creating accountability, but required an influential community partner and adequate community resources. Concerns about disempowering clients and blurring roles were voiced, and potential to increase provider job satisfaction was identified. CONCLUSIONS: Benefits and drawbacks of adopting new tools and practices related to social needs-targeted care are strongly influenced by the community context. For the adoption of community resource referral platforms, the outer setting is particularly relevant; adoption readiness is best assessed at the community or regional level rather than the clinic system level. While screening tools are much easier than referral platforms for clinics to adopt, the ability to address identified needs remains heavily based on the outer setting.

Immediate Postpartum Long-Acting Reversible Contraception Programs in Texas Hospitals Following Changes to Medicaid Reimbursement Policy.

OBJECTIVES: Provision of long-acting reversible contraception (LARC) after delivery and prior to discharge is safe and advantageous, yet few Texas hospitals offer this service. Our study describes experiences of Texas hospitals that implemented immediate postpartum LARC (IPLARC) programs, in order to inform the development of other IPLARC programs and guide future research on system-level barriers to broader adoption. METHODS: Eight Texas hospitals that had implemented an IPLARC program were identified, and six agreed to participate in the study. Interviews with 19 key hospital staff covered (1) factors that led the development of an IPLARC program; (2) billing, pharmacy, and administrative operations related to implementation; (3) patient demand and readiness; (4) the consent process; (5) staff training; and (6) hospital plans for monitoring and evaluation of IPLARC services. RESULTS: Most hospitals in this study primarily served Medicaid and un- or under-insured populations. Participants from all six hospitals perceived high levels of patient demand for IPLARC and provider interest in providing this service. The major challenges were related to financing IPLARC programs. Participants from half of the hospitals reported that leadership had concerns about financial viability of providing IPLARC. The hospitals with the longest-running IPLARC programs were safety net hospitals with family planning training programs. CONCLUSIONS FOR PRACTICE: We found that hospitals with IPLARC programs all had strong support from both providers and hospital leadership and had funding sources to offset costs that were not reimbursed. Strategies to reduce the financial risks related to IPLARC provision could provide the impetus for new programs to launch and support their sustainability.

Promoting Influenza Vaccination Among an ACA Health Plan Subscriber Population: A Randomized Trial.

PURPOSE: To assess the effectiveness of an intervention to promote influenza vaccination among members of an Affordable Care Act (ACA) insurance plan. DESIGN: Randomized controlled trial. SETTING: Messages were delivered by a community-based, nonprofit health insurance provider to its members in Central Texas. PARTICIPANTS: Adult subscribers for whom either a phone number or an e-mail address was available (n = 25 649). INTERVENTION: Participants were randomly assigned to be sent (1) no messages, (2) messages encouraging influenza vaccination via e-mails and texts, and (3) messages encouraging influenza vaccination through e-mails, texts, and postal mail. Messages were sent between September 12, 2017 and November 17, 2017. MEASURES: Influenza vaccination was determined using medical and pharmacy claims. ANALYSIS: Rate differences and 95% confidence intervals between each exposure condition were calculated for the overall population and by subgroups. RESULTS: The vaccination rate by December 31, 2017 was 16.9%. Those sent both electronic messages and postal mail were significantly more likely to be vaccinated than those who were not sent messages (rate difference: 2.5%; 95% confidence interval [CI]: 1.4-3.6) and those who were sent electronic messages only (rate difference: 1.6%; 95% CI: 0.5-2.8). CONCLUSION: A combination of messages delivered via text, e-mail, and postal mail generated a modest but significant positive effect on influenza vaccine rates in an ACA plan population. The postal mail component was essential for achieving this effect.

The Effect of New Shower Facilities on Physical Activity Behaviors of Employees: A Quasi-experiment.

BACKGROUND: This quasi-experimental study assessed the effects of new workplace showers on physical activity behaviors in a sample of downtown employees in Austin, TX. METHODS: The study design was quasi-experimental with 2 comparison groups. Data were collected via internet-based surveys before and 4 months after shower installation at 1 worksite. Differences across study groups in the ranks of change in past-week minutes of physical activity from baseline to follow-up were assessed. Adjusted odds ratios and 95% confidence intervals for reporting an increase of ≥10 min past-week physical activity and workday physical activity among those with new showers and existing showers relative to those with no showers were also assessed. RESULTS: No significant differences in changes in physical activity from baseline to follow-up across study groups were found. One-quarter of participants with new workplace showers and 46.9% of those with existing workplace showers at baseline reported ever using the showers. CONCLUSIONS: This prospective study did not find significant changes in employee physical activity 4 months after installation of worksite showers. Worksite shower users were highly active at baseline, suggesting a possible early adopter effect, with potential for diffusion. Future studies may benefit from longer exposure times and larger samples.

Does Parents' Social Cohesion Influence Their Perception of Neighborhood Safety and Their Children's Active Commuting to and From School?

BACKGROUND: The role of parents' perceptions of the neighborhood environment in determining children's active commuting to and from school (ACS) is understudied. This study examined the association between parents' perceptions of neighborhood social cohesion, perceived neighborhood safety, and their children's ACS. METHODS: This cross-sectional analysis (n = 857 from 81 elementary schools in Texas) examined baseline data from the Texas Childhood Obesity Prevention Policy Evaluation project. Participants had a mean age of 9.6 (0.6) years, and 50% were girls. Mixed effects logistic regression models were used to assess gender-stratified associations between parent's perceived social cohesion and children's ACS and their perception of neighborhood safety. RESULTS: A positive significant association was observed between levels of perceived social cohesion and children's ACS for boys (P = 0.047); however, an inverse significant association was observed among girls (P = 0.033). Parents of boys living in neighborhoods with medium to high social cohesion were more likely to perceive their neighborhood as safe compared with parents living in neighborhoods with low social cohesion, though nonsignificant. Perceived neighborhood safety for walking and biking was associated with greater ACS among boys (P = 0.003). CONCLUSIONS: Our study findings indicate that both social and physical environments are important factors in determining ACS among boys.

Environmental Correlates of Recreational Walking in the Neighborhood.

PURPOSE: To assess environmental correlates of neighborhood recreational walking. DESIGN: The study used a cross-sectional survey. SETTING: The study was conducted in the local community. SUBJECTS: Participants were adults who recently relocated and walk for recreation in their current neighborhood. MEASURES: The outcome measure was participant-reported neighborhood recreational walking in participants' prior neighborhood. Exposure measures were (1) participant-reported social and environmental characteristics of the prior neighborhood and (2) geographic information system-derived environmental characteristics assessed within a buffer around participant's prior address. ANALYSIS: Participants reporting current neighborhood recreational walking (n = 231) were characterized by whether they walked for recreation in their prior neighborhood. Associations between neighborhood characteristics and neighborhood recreational walking were assessed using logistic regression. RESULTS: Neighborhood recreational walking was associated with perceptions of the presence of recreational facilities (odds ratio [OR] = 2.49, 95% confidence interval [CI] = 1.29-4.84), interesting things to see (OR = 2.82, 95% CI = 1.46-5.45), and others being active (OR = 3.56, 95% CI = 1.80-7.05), and was inversely associated with concerns about crime (OR = .40, 95% CI = .20-.77) and traffic (OR = .43, 95% CI = .22-.87). This behavior was associated with objectively measured presence of walking trails (OR = 3.58, 95% CI = 1.07-4.46), percentage of street length with speed limits ≤25 mph (OR = 1.31 for 10% increase, 95% CI = 1.08-1.61), and percentage of tree canopy coverage (OR = 1.55 for 10% increase, 95% CI = 1.12-2.14). CONCLUSION: Recreational walking may be influenced by environmental factors that support a safe, enjoyable, and social experience, attributes that are not necessarily prioritized in transportation walking. Outcome and exposure specificity are important when studying recreational walking.

Sociodemographic Factors, Population Density, and Bicycling for Transportation in the United States.

BACKGROUND: Transportation bicycling is a behavior with demonstrated health benefits. Population-representative studies of transportation bicycling in United States are lacking. This study examined associations between sociodemographic factors, population density, and transportation bicycling and described transportation bicyclists by trip purposes, using a US-representative sample. METHODS: This cross-sectional study used 2009 National Household Travel Survey datasets. Associations among study variables were assessed using weighted multivariable logistic regression. RESULTS: On a typical day in 2009, 1% of Americans older than 5 years of age reported a transportation bicycling trip. Transportation cycling was inversely associated with age and directly with being male, with being white, and with population density (≥ 10,000 vs < 500 people/square mile: odd ratio, 2.78, 95% confidence interval, 1.54-5.05). Those whose highest level of education was a high school diploma or some college were least likely to bicycle for transportation. Twenty-one percent of transportation bicyclists reported trips to work, whereas 67% reported trips to social or other activities. CONCLUSIONS: Transportation bicycling in the United States is associated with sociodemographic characteristics and population density. Bicycles are used for a variety of trip purposes, which has implications for transportation bicycling research based on commuter data and for developing interventions to promote this behavior.

Measuring the bias, precision, accuracy, and validity of self-reported height and weight in assessing overweight and obesity status among adolescents using a surveillance system.

BACKGROUND: Evidence regarding bias, precision, and accuracy in adolescent self-reported height and weight across demographic subpopulations is lacking. The bias, precision, and accuracy of adolescent self-reported height and weight across subpopulations were examined using a large, diverse and representative sample of adolescents. A second objective was to develop correction equations for self-reported height and weight to provide more accurate estimates of body mass index (BMI) and weight status. METHODS: A total of 24,221 students from 8th and 11th grade in Texas participated in the School Physical Activity and Nutrition (SPAN) surveillance system in years 2000-2002 and 2004-2005. To assess bias, the differences between the self-reported and objective measures, for height and weight were estimated. To assess precision and accuracy, the Lin's concordance correlation coefficient was used. BMI was estimated for self-reported and objective measures. The prevalence of students' weight status was estimated using self-reported and objective measures; absolute (bias) and relative error (relative bias) were assessed subsequently. Correction equations for sex and race/ethnicity subpopulations were developed to estimate objective measures of height, weight and BMI from self-reported measures using weighted linear regression. Sensitivity, specificity and positive predictive values of weight status classification using self-reported measures and correction equations are assessed by sex and grade. RESULTS: Students in 8th- and 11th-grade overestimated their height from 0.68cm (White girls) to 2.02 cm (African-American boys), and underestimated their weight from 0.4 kg (Hispanic girls) to 0.98 kg (African-American girls). The differences in self-reported versus objectively-measured height and weight resulted in underestimation of BMI ranging from -0.23 kg/m2 (White boys) to -0.7 kg/m2 (African-American girls). The sensitivity of self-reported measures to classify weight status as obese was 70.8% and 81.9% for 8th- and 11th-graders, respectively. These estimates increased when using the correction equations to 77.4% and 84.4% for 8th- and 11th-graders, respectively. CONCLUSIONS: When direct measurement is not practical, self-reported measurements provide a reliable proxy measure across grade, sex and race/ethnicity subpopulations of adolescents. Correction equations increase the sensitivity of self-report measures to identify prevalence of overall overweight/obesity status.

Increasing access to healthful foods: a qualitative study with residents of low-income communities.

BACKGROUND: Inadequate access to healthful foods has been identified as a significant barrier to healthful dietary behaviors among individuals who live in low-income communities. The purpose of this study was to gather low-income community members' opinions about their food purchasing choices and their perceptions of the most effective ways to increase access to healthful foods in their communities. METHODS: Spanish and English focus groups were conducted in low-income, ethnically-diverse communities. Participants were asked about their knowledge, factors influencing their food purchasing decisions, and their perceptions regarding solutions to increase access to healthful foods. RESULTS: A total of 148 people participated in 13 focus groups. The majority of participants were female and ethnically diverse (63% Hispanic, 17% African American, 16% Caucasian, and 4% "other"). More than 75% of the participants reported making less than $1999 USD per month. Participants reported high levels of knowledge and preference for healthful foods. The most important barriers influencing healthful shopping behaviors included high price of healthful food, inadequate geographical access to healthful food, poor quality of available healthful food, and lack of overall quality of the proximate retail stores. Suggested solutions to inadequate access included placement of new chain supermarkets in their communities. Strategies implemented in convenience stores were not seen as effective. Farmers' markets, with specific stipulations, and community gardens were regarded as beneficial supplementary solutions. CONCLUSION: The results from the focus groups provide important input from a needs assessment perspective from the community, identify gaps in access, and offer potential effective solutions to provide direction for the future.

Parental safety concerns and active school commute: correlates across multiple domains in the home-to-school journey.

BACKGROUND: Empirical evidence of the relationship between safety concerns and walking to school (WTS) is growing. However, current research offers limited understanding of the multiple domains of parental safety concerns and the specific mechanisms through which parents articulate safety concerns about WTS. A more detailed understanding is needed to inform environmental and policy interventions. This study examined the relationships between both traffic safety and personal safety concerns and WTS in the U.S. METHODS: This cross-sectional analysis examined data from the Texas Childhood Obesity Prevention Policy Evaluation (T-COPPE) project, an evaluation of state-wide obesity prevention policy interventions. All study data were from the survey (n=830) of parents with 4th grade students attending 81 elementary schools across Texas, and living within two miles from their children's schools. Traffic safety and personal safety concerns were captured for the home neighborhood, en-route to school, and school environments. Binary logistic regression analysis was used to assess the odds of WTS controlling for significant covariates. RESULTS: Overall, 18% of parents reported that their child walked to school on most days of the week. For traffic safety, students were more likely to walk to school if their parent reported favorable perceptions about the following items in the home neighborhood environment: higher sidewalk availability, well maintained sidewalks and safe road crossings. For the route to school, the odds of WTS were higher for those who reported "no problem" with each one of the following: traffic speed, amount of traffic, sidewalks/pathways, intersection/crossing safety, and crossing guards, when compared to those that reported "always a problem". For personal safety in the en-route to school environment, the odds of WTS were lower when parents reported concerns about: stray or dangerous animals and availability of others with whom to walk. CONCLUSIONS: Findings offered insights into the specific issues that drive safety concerns for elementary school children's WTS behaviors. The observed associations between more favorable perceptions of safety and WTS provide further justification for practical intervention strategies to reduce WTS barriers that can potentially bring long-term physical activity and health benefits to school-aged children.