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.

Local School Wellness Policy as a Means to Advance Whole School, Whole Community, Whole Child: Assessing Alignment in Los Angeles County.

BACKGROUND: District wellness policies provide an avenue to advance the Whole School, Whole Community, Whole Child (WSCC) model. The extent to which wellness policies currently align with WSCC is unclear; to-date, tools have been unavailable to examine this issue. METHODS: We reviewed written health-focused policies among 37 school districts in Los Angeles County in 2017 utilizing a 54-item tool designed to examine the quality of policies in the 10 WSCC domains. Descriptive analyses explored overall and domain-specific comprehensiveness and strength; simple negative binomial regression models examined differences in the policy quality and structure by legislated status. RESULTS: Approximately half of expected policies were present in wellness policies (mean comprehensiveness score = 52.65, ±18.09), < 20% were strong (mean strength score = 16.97, ±8.05). Content in WSCC domains addressed by legislative mandates was significantly more comprehensive and stronger, and more frequently located within the wellness policies, relative to content in non-legislated domains. CONCLUSIONS: Opportunities exist for better alignment of wellness policies with WSCC. Education and health practitioners can utilize the tool developed for this study to identify priority areas where policy support is needed in their jurisdictions. Additional efforts are needed to help schools facilitate and document practice gains around WSCC-aligned policies.

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.

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.

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.

Review of Education-Focused Health Impact Assessments Conducted in the United States.

BACKGROUND: Health impact assessment (HIA) provides a structured process for examining the potential health impacts of proposed policies, plans, programs, and projects. This study systematically reviewed HIAs conducted in the United States on prekindergarten, primary, and secondary education-focused decisions. METHODS: Relevant HIA reports were identified from web sources in late 2015. Key data elements were abstracted from each report. Four case studies were selected to highlight diversity of topics, methods, and impacts of the assessment process. RESULTS: Twenty HIAs completed in 2003-2015 from 8 states on issues related to prekindergarten through secondary education were identified. The types of decisions examined included school structure and funding, transportation to and from school, physical modifications to school facilities, in-school physical activity and nutrition, and school discipline and climate. Assessments employed a range of methods to characterize the nature, magnitude, and severity of potential health impacts. Assessments fostered stakeholder engagement and provided health-promoting recommendations, some of which were subsequently incorporated into school policies. CONCLUSIONS: Health impact assessment is a promising tool that education, health, and other stakeholders can use to maximize the health and well-being of students, families, and communities.

Youth Descriptions of Mental Health Needs and Experiences with School-based Services: Identifying Ways to Meet the Needs of Underserved Adolescents.

While schools serve as a common entry point into mental health services for underserved youth, engagement of students in need of care remains a problem. Little is known about the ways schools can best address students' mental health needs, especially from the perspective of youth who struggle to attend school, a vulnerable group with a high burden of mental health problems. A qualitative descriptive approach was used to analyze data from in-depth interviews with a sample of 18 youth with a history of school truancy and mental health problems. Analyses explored how youth expressed mental health symptoms, and their trajectories through, and perceptions of, school-based mental health services. Results suggest that participants experienced multiple, overlapping symptoms; only a portion had their needs addressed. The quality of relationships with school staff and the perceived efficacy of treatment affected service trajectories. Promising school-based approaches to address students' mental health needs are discussed.

A Framework for Implementing the National Diabetes Prevention Program in Los Angeles County.

INTRODUCTION: Preventing type 2 diabetes is a public health priority in the United States. An estimated 86 million Americans aged 20 years or older have prediabetes, 90% of whom are unaware they have it. The National Diabetes Prevention Program (NDPP) has the potential to reduce the incidence of type 2 diabetes; however, little is known about the best way to institutionalize such a program in a jurisdiction with a racially/ethnically diverse population. The objective of this study was to develop a practice-grounded framework for implementing the NDPP in Los Angeles County. METHODS: In 2015, the Los Angeles County Department of Public Health (LACDPH) partnered with Ad Lucem Consulting to conduct a 3-stage formative assessment that consisted of 1) in-depth interviews with key informants representing community-based organizations to learn about their experiences implementing the NDPP and similar lifestyle-change programs and 2) 2 strategic planning sessions to obtain input and feedback from the Los Angeles County Diabetes Prevention Coalition. LACDPH identified core activities to increase identification of people with type 2 diabetes and referral and enrollment of eligible populations in the NDPP. RESULTS: We worked with LACDPH and key informants to develop a 3-pronged framework of core activities to implement NDPP: expanding outreach and education, improving health care referral systems and protocols, and increasing access to and insurance coverage for NDPP. The framework will use a diverse partner network to advance these strategies. CONCLUSION: The framework has the potential to identify people with prediabetes and to expand NDPP among priority populations in Los Angeles County and other large jurisdictions by using a diverse partner network.

Relationships Among Student, Staff, and Administrative Measures of School Climate and Student Health and Academic Outcomes.

BACKGROUND: School climate is an integral part of a comprehensive approach to improving the well-being of students; however, little is known about the relationships between its different domains and measures. We examined the relationships between student, staff, and administrative measures of school climate to understand the extent to which they were related to each other and student outcomes. METHODS: The sample included 33,572 secondary school students from 121 schools in Los Angeles County during the 2014-2015 academic year. A multilevel regression model was constructed to examine the association between the domains and measures of school climate and 5 outcomes of student well-being: depressive symptoms or suicidal ideation, tobacco use, alcohol use, marijuana use, and grades. RESULTS: Student, staff, and administrative measures of school climate were weakly correlated. Strong associations were found between student outcomes and student reports of engagement and safety, while school staff reports and administrative measures of school climate showed limited associations with student outcomes. CONCLUSIONS: As schools seek to measure and implement interventions aimed at improving school climate, consideration should be given to grounding these efforts in a multidimensional conceptualization of climate that values student perspectives and includes elements of both engagement and safety.

Setting a minimum age for juvenile justice jurisdiction in California.

Purpose Despite the existence of minimum age laws for juvenile justice jurisdiction in 18 US states, California has no explicit law that protects children (i.e. youth less than 12 years old) from being processed in the juvenile justice system. In the absence of a minimum age law, California lags behind other states and international practice and standards. The paper aims to discuss these issues. Design/methodology/approach In this policy brief, academics across the University of California campuses examine current evidence, theory, and policy related to the minimum age of juvenile justice jurisdiction. Findings Existing evidence suggests that children lack the cognitive maturity to comprehend or benefit from formal juvenile justice processing, and diverting children from the system altogether is likely to be more beneficial for the child and for public safety. Research limitations/implications Based on current evidence and theory, the authors argue that minimum age legislation that protects children from contact with the juvenile justice system and treats them as children in need of services and support, rather than as delinquents or criminals, is an important policy goal for California and for other national and international jurisdictions lacking a minimum age law. Originality/value California has no law specifying a minimum age for juvenile justice jurisdiction, meaning that young children of any age can be processed in the juvenile justice system. This policy brief provides a rationale for a minimum age law in California and other states and jurisdictions without one.

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.

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.

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.

Self-Efficacy as a Mediator of the Relationship Between the Perceived Food Environment and Healthy Eating in a Low Income Population in Los Angeles County.

While previous studies have described psychosocial and environmental factors that contribute to healthy eating, much remains unknown about the interactions between them. We assessed the relationship between the perceived food environment, self-efficacy and fruit and vegetable consumption, using data from a sample of racially diverse, low-income adult clientele of five public health centers in Los Angeles County (n = 1503). We constructed a negative binomial regression model to examine the association between perceived food environment and the number of fruits and vegetables consumed. For every one point increase on the perceived food environment scale, individuals ate about 5% more fruits and vegetables (95% CI 1.007, 1.089), controlling for other covariates. Self-efficacy was shown to be a significant mediator (mediated effect = 0.010; 95% CI 0.002, 0.020), accounting for 22.9% of the effect. Efforts to increase access to healthy options may not only improve eating behaviors, but also influence individuals' beliefs that they can eat healthfully.

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.

Understanding Racial and Ethnic Disparities in Arrest: The Role of Individual, Home, School, and Community Characteristics.

Contact with the justice system can lead to a range of poor health and social outcomes. While persons of color are disproportionately represented in both the juvenile and criminal justice systems, reasons for these patters remain unclear. This study sought to examine the extent and sources of differences in arrests during adolescence and young adulthood among blacks, whites, and Hispanics in the USA. Multilevel cross-sectional logistic regression analyses were conducted using data from waves I and IV of the National Longitudinal Study of Adolescent to Adult Health (n = 12,752 respondents). Results showed significantly higher likelihood of having ever been arrested among blacks, when compared to whites, even after controlling for a range of delinquent behaviors (odds ratio = 1.58, 95 % confidence interval = 1.27, 1.95). These black-white disparities were no longer present after accounting for racial composition of the neighborhood, supporting the growing body of research demonstrating the importance of contextual variables in driving disproportionate minority contact with the justice system.

Dissemination, Implementation, and Improvement Science Research in Population Health: Opportunities for Public Health and CTSAs.

IMPORTANCE: The complex, dynamic nature of health systems requires dissemination, implementation, and improvement (DII) sciences to effectively translate emerging knowledge into practice. Although they hold great promise for informing multisector policies and system-level changes, these methods are often not strategically used by public health. OBJECTIVES AND METHODS: More than 120 stakeholders from Southern California, including the community, federal and local government, university, and health services were convened to identify key priorities and opportunities for public health departments and Clinical and Translational Science Awards programs (CTSAs) to advance DII sciences in population health. MAIN OUTCOMES: Participants identified challenges (mismatch of practice realities with narrowly focused research questions; lack of iterative learning) and solutions (using methods that fit the dynamic nature of the real world; aligning theories of change across sectors) for applying DII science research to public health problems. Pragmatic steps that public health and CTSAs can take to facilitate DII science research include: employing appropriate study designs; training scientists and practicing professionals in these methods; securing resources to advance this work; and supporting team science to solve complex-systems issues. CONCLUSIONS: Public health and CTSAs represent a unique model of practice for advancing DII research in population health. The partnership can inform policy and program development in local communities.

Self-reported use of Supplemental Nutrition Assistance Program benefits to purchase soda in a public health center population: Los Angeles County, California, 2012.

To better inform local program planning for the Supplemental Nutrition Assistance Program (SNAP), the Los Angeles County Department of Public Health used self-reported data from a public health center population to examine the prevalence of benefits used to purchase soda. We performed statistical analyses, including multivariable regression modeling, using data from a local health and nutrition examination survey. The survey response rate was 69% (n=1,503). More than one-third of survey participants reported receiving, or living in a household where someone receives, nutrition assistance benefits. When asked, 33% (n=170) reported using these benefits to purchase soda "sometimes" and 18% (n=91) reported "often" or "always," suggesting that the use of program benefits to purchase soda was not uncommon in this subpopulation. These findings have meaningful policy and planning implications, as they contribute to ongoing dialogue about strategies for optimizing nutrition among SNAP recipients.