Research on the Translation and Implementation of Stepping On in Three Wisconsin Communities.

OBJECTIVE: Falls are a leading cause of injury death. Stepping On is a fall prevention program developed in Australia and shown to reduce falls by up to 31%. The original program was implemented in a community setting, by an occupational therapist, and included a home visit. The purpose of this study was to examine aspects of the translation and implementation of Stepping On in three community settings in Wisconsin. METHODS: The investigative team identified four research questions to understand the spread and use of the program, as well as to determine whether critical components of the program could be modified to maximize use in community practice. The team evaluated program uptake, participant reach, program feasibility, program acceptability, and program fidelity by varying the implementation setting and components of Stepping On. Implementation setting included type of host organization, rural versus urban location, health versus non-health background of leaders, and whether a phone call could replace the home visit. A mixed methodology of surveys and interviews completed by site managers, leaders, guest experts, participants, and content expert observations for program fidelity during classes was used. RESULTS: The study identified implementation challenges that varied by setting, including securing a physical therapist for the class and needing more time to recruit participants. There were no implementation differences between rural and urban locations. Potential differences emerged in program fidelity between health and non-health professional leaders, although fidelity was high overall with both. Home visits identified more home hazards than did phone calls and were perceived as of greater benefit to participants, but at 1 year no differences were apparent in uptake of strategies discussed in home versus phone visits. CONCLUSION: Adaptations to the program to increase implementation include using a leader who is a non-health professional, and omitting the home visit. Our research demonstrated that a non-health professional leader can conduct Stepping On with adequate fidelity, however non-health professional leaders may benefit from increased training in certain aspects of Stepping On. A phone call may be substituted for the home visit, although short-term benefits are greater with the home visit.

The public health approach to reducing suicide: opportunities for curriculum development in psychiatry residency training programs.

The authors review the current status of suicide prevention curricula in psychiatry training programs, describe the public health approach to suicide prevention, discuss public health strategies for reducing suicides and the unique role played by psychiatrists with respect to suicide prevention, and offer public health-oriented suicide prevention curriculum guidelines for psychiatry residents.

Motor vehicle crashes associated with alcohol: child passenger injury and restraint use.

BACKGROUND: The role of alcohol in fatal motor vehicle crashes involving children has been well established. However, the nonfatal injury burden of alcohol on child passengers has not been comprehensively assessed. PURPOSE: This study sought to determine injury burden and restraint use in child passengers aged 1-15 years in alcohol-related motor vehicle crashes. METHODS: A retrospective cohort study including all people involved in all crashes with an injury or at least $1000 property damage occurring in Wisconsin in 2007 and involving at least one child passenger aged 1-15 years. RESULTS: A total of 22,464 child passengers were involved in motor vehicle crashes in Wisconsin in 2007; 2.5% (n=570) were in alcohol-related crashes. Child passengers in alcohol-related crashes experienced twice the risk of injury compared to non-alcohol-related crashes (risk ratio [RR]=2.42, 95% CI=2.08, 2.80). Two-vehicle crashes that were alcohol-related were more than two times more likely to result in child injury than those that were not (RR=2.78, 95% CI=2.30, 3.35). In alcohol-related crashes, the risk of injury in children was higher if they were passengers in the alcohol-related vehicle compared to the non-alcohol-related vehicle (RR=1.35, 95% CI=1.01, 1.79). Inappropriate restraint of child passengers was higher in alcohol-related vehicles (34.5% vs 17.1%, p<0.00005), particularly in the group aged 4-7 years (70.8% vs 44.9% inappropriately restrained). CONCLUSIONS: Motor vehicle crashes resulting from alcohol-related driving significantly increased child passenger injury and were associated with inappropriate child passenger restraint. Several evidence-based policies are recommended to address this public health problem.

Use of child death review to inform sudden unexplained infant deaths occurring in a large urban setting.

OBJECTIVE: To illustrate the benefits and utility of the child death review (CDR) reporting system when examining risk factors associated with infant death occurring within two subgroups of sudden unexpected infant deaths (SUID)-unintentional suffocation and sudden infant death syndrome (SIDS)-in a large urban county in Wisconsin. DESIGN: Retrospective CDR data were analysed, 2007-2008, for Milwaukee County, Wisconsin. PATIENTS OR SUBJECTS: Unintentional suffocation and SIDS infant deaths under 1 year of age in Milwaukee County, Wisconsin, 2007-2008, with a CDR record indicating a death in a sleep environment. Main outcome measure Study examined demographic characteristics, bed-sharing, incident sleep location, position of child when put to sleep, position of child when found, child's usual sleep place, crib in home, and other objects found in sleep environment. RESULTS: Unintentional suffocation (n=11) and SIDS (n=40) classified deaths with CDR data made up 18% (51/283) of all infant deaths in Milwaukee County from 2007 to 2008. The majority of infants who died of unintentional suffocation (n=9, 81.8%) or SIDS (n=26, 65.0%) were black and under the age of 3 months. Bed-sharing was involved in most of the unintentional suffocation deaths (n=10, 90.9%) and the SIDS deaths (n=28, 70.0%). All unintentional suffocation deaths (n=11, 100%) and the majority of SIDS deaths (n=31, 77.5%) took place in a non-crib sleeping environment. CONCLUSIONS: The study demonstrates how CDR provides enhanced documentation of risk factors to help steer prevention efforts regarding SUID deaths in a community and reaffirms infants in an unsafe sleep environment have an increased risk of death.

The burden of suicide in Wisconsin's older adult population.

INTRODUCTION: Suicide rates in the older adult population are disproportionately high, yet most studies focus on youth suicide. This study characterized risk factors for elder suicide in Wisconsin. METHODS: Wisconsin residents aged > or =65 who committed suicide from 2001-2006 were identified using the Violent Injury Reporting System (VIRS; 2001-2003) and the Wisconsin Violent Death Reporting System (WVDRS; 2004-2006). Multivariate regression was used to determine the risk of suicide and to adjust crude rates. Suicide circumstances and methods were also examined. RESULTS: From 2001-2006, the rate of suicide of those > or =65 was 12.4 per 100,000 per year, lower than the national average of 14.7 per 100,000. Multivariate analysis in Caucasians found that compared to married individuals, those widowed, divorced, or never married had a 2.5- to nearly 5-fold increase in risk of suicide death. Males aged 65-74 had almost a 7-fold increased risk compared to females of that age, and the risk increased for males as they aged, compared to females 65-74 years old. Almost 40% of the cases had a medical examiner or coroner report that the victim had a diagnosed mental illness. Forty-two percent of victims had documented alcohol toxicology screening; of these, 16% were positive for alcohol at the time of death. The most common method of suicide was firearm use (66.9%). DISCUSSION: Being single, male, and a male advancing in age are risk factors of suicide in the elderly. Health care workers, community advocates, and public health workers should be cognizant of these risk factors to facilitate early recognition and intervention.

Sustaining quality improvement in community health centers: perceptions of leaders and staff.

The Health Disparities Collaboratives are the largest national quality improvement (QI) initiatives in community health centers. This article identifies the incentives and assistance personnel believe are necessary to sustain QI. In 2004, 1006 survey respondents (response rate 67%) at 165 centers cited lack of resources, time, and staff burnout as common barriers. Release time was the most desired personal incentive. The highest funding priorities were direct patient care services (44% ranked no. 1), data entry (34%), and staff time for QI (26%). Participants also needed help with patient self-management (73%), information systems (77%), and getting providers to follow guidelines (64%).

Evaluating interventions to reduce health care disparities: an RWJF program.

The Robert Wood Johnson Foundation's Finding Answers: Disparities Research for Change program funds evaluation of interventions to reduce racial and ethnic disparities in cardiovascular disease, depression, and diabetes. Of the 177 applications received in 2006, the most prevalent proposed interventions were patient or provider education (57 percent), community health workers (25 percent), case management (24 percent), integrated health care (24 percent), and cultural modification (24 percent). Policy interventions, including pay-for-performance (P4P) incentives, were lacking. The eleven grantees target patients, providers, patient-provider communication, health care organizations, and communities in innovative ways. We identify important future research questions.

The perceived financial impact of quality improvement efforts in community health centers.

We administered surveys to 100 chief executive officers (CEOs) of community health centers to determine their perceptions of the financial impact of the Health Disparities Collaboratives, a national quality improvement initiative. One third of the CEOs believed that the HDC had a negative financial impact on their health center, and this perception was significantly correlated with centers having a higher proportion of uninsured patients. Performance-based payment incentives may improve care but may also add new financial burdens to facilities that treat the uninsured population. As such, a provider's payer mix may need to be considered in the design of QI programs if they are to be sustainable.