Kaiser Permanente's Social Needs Network for Evaluation and Translation Empirical Research Agenda.

Introduction: Healthcare systems such as Kaiser Permanente are increasingly focusing on patients' social health. However, there is limited evidence to guide social health integration strategy. The purpose of this study was to identify social health research opportunities using a stakeholder-driven process. Methods: A modified Concept Mapping approach was implemented from June 2021 to February 2022. Stakeholders (n=746) received the prompt, "One thing I wish we knew more about to advance my work addressing social health..." An inductive content analysis approach was used to assign topics and synthesize and refine research-focused statements into research questions. Questions were then rated on impact and priority by researcher stakeholders (n=16). Mean impact and priority scores and an overall combined score were calculated. Question rankings were generated using the combined score. Results: Brainstorming produced 148 research-focused statements. A final list of 59 research questions was generated for rating. Question topics were (1) Data, Measures, and Metrics; (2) Intervention Approach and Impact; (3) Technology; (4) Role of Healthcare Systems; (5) Community-Based Organizations; (6) Equity; (7) Funding; and (8) Social Health Integration. On a scale from 1 (low) to 10 (high), the mean impact score was 6.12 (range=4.14-7.79), and the mean priority score was 5.61 (range=3.07-8.64). Twenty-four statements were rated as both high impact (>6.12) and high priority (>5.61). Conclusions: The broad range of topics with high impact and priority scores reveals how nascent the evidence base is, with fundamental research on the nature of social risk and health system involvement still needed.

Participant perspectives on the impact of receiving medically tailored meals on post-hospitalization.

OBJECTIVE: The objective of this program evaluation was to measure the impact of a medically tailored meals (MTM) intervention on participants' self-reported recovery and satisfaction while recovering from a recent hospitalization. DESIGN: A qualitative design was employed using a brief survey among all participants at the end of the intervention and phone interviews with a subset of participants. SAMPLE: Participants in this study were recently discharged from the hospital and were members of (redacted for review) who had received 2-4 weeks of MTM. MEASUREMENTS: The survey assessed overall satisfaction with the meals and perceived impact on their recovery after hospitalization (81% response rate). Interview questions asked how they felt the meals may have helped while recovering (e.g., helped them financially or with their ability to remain independent). RESULTS: Among survey participants, 65% were extremely or very satisfied with their meals. Reasons that MTM were helpful while they were recovering included having sufficient food to eat, having healthy food to eat, the convenience of the meals, and ease of preparing the meals. CONCLUSIONS: Participants receiving MTM were generally very satisfied with the program. Including nutrition education and more flexibility in quantity and frequency of food may improve satisfaction and consumption of food.

Comparing two durations of medically tailored meals posthospitalization: A randomized clinical trial.

BACKGROUND: Medically tailored meals (MTM) may be beneficial to patients after hospital discharge. OBJECTIVE: To determine if 2 versus 4 weeks of MTM posthospitalization will improve patient outcomes. DESIGN: Randomized unblinded trial. SETTINGS AND PARTICIPANTS: Six hundred and fifty patients pending hospital discharge with at least one chronic condition. INTERVENTION: One MTM a day for 2 versus 4 weeks. MAIN OUTCOME AND MEASURES: The primary outcome was a change from baseline to 60 days in the Hospital Anxiety Depression Scale (HADS). Secondary outcomes measured change in the Katz activities of daily living (ADLs), DETERMINE nutritional risk, and all-cause emergency department (ED) visits and rehospitalizations. RESULTS: From baseline to 60 days the HADS anxiety subscale changed 5.4-4.9 in the 2-week group (p = .03) and 5.4-5.3 in the 4-week group (p = .49); the difference in change between groups 0.4 (p = .25). HADS changed 5.4-4.8 in the 2-week group (p = .005) and 5.3-5.1 in the 4-week group (p = .34); the difference in change between groups 0.4 (p = .18). ADL score changed from 5.3 to 5.6 in the 2-week group (p ≤ .0001) and 5.2-5.5 in the 4-week group (p ≤ .0001); the difference in change between groups -0.01 (p = .90). The DETERMINE changed in the 2-week group from 7.2 to 6.4 (p = .0006) and from 7 to 6.7 in the 4-week group (p = .19); the difference in change between groups 0.5 (p = .13). There was no difference in ED visits and rehospitalizations between groups or time to rehospitalization. CONCLUSIONS: Different durations of short-term MTM did not affect patient-centered or utilization outcomes.

Social risk factors among individuals with a history of cancer during the COVID-19 pandemic.

PURPOSE: The coronavirus disease (COVID-19) pandemic and its economic consequences may disproportionately impact cancer survivors and their overall health-related quality of life. The objective of this study was to examine whether cancer survivors experienced higher levels of financial strain or food insecurity compared to those without a history of cancer. METHODS: Kaiser Permanente Research Bank (KPRB) study participants were invited to complete a series of electronic surveys starting April 2020 to assess the impact of the COVID-19 pandemic. Participants who completed the initial survey and one follow-up survey were included. The odds of financial strain and food insecurity in those with and without a history of cancer were estimated using multinomial logistic regression. RESULTS: Cancer survivors (n = 16,231) had lower odds of reporting "somewhat hard" (AOR = 0.77) and "very hard" (AOR = 0.67) financial strain, and food insecurity "sometimes" (AOR = 0.70) and "often" (AOR = 0.55) compared to those with no history of cancer (n = 88,409). Non-Hispanic (NH) Black and Hispanic cancer survivors had higher odds compared to NH Whites of reporting financial strain and food insecurity. Smokers and those with multiple comorbidities had higher odds of reporting financial strain and food insecurity among cancer survivors. CONCLUSIONS: While cancer survivors overall did not report greater financial strain or food insecurity than individuals without a history of cancer, subsets of cancer survivors are experiencing greater social risks during the pandemic and should be prioritized for screening for social risk factors. IMPLICATIONS FOR CANCER SURVIVORS: Incorporating screening for social risk factors into care coordination workflows for subsets of cancer survivors should be a priority.

A Natural Experiment: Results of Community-Designed Park Improvements on Park Use and Physical Activity.

The objective of this study was to assess if built environment changes to two suburban parks that involved extensive community engagement and physical activity programming increased park use and physical activity. This study employed a natural experiment evaluation design where community engagement informed the redesign of two neighborhood parks. Community engagement in the redesign of the parks was tracked as was the diversity of the partners on the steering committee and participation by community members in the process. Before and after park improvements, data were collected using the System for Observing Play and Recreation in Communities (SOPARC) instrument to measure change in use and activity level in each park. Park use increased at both parks, but physical activity levels did not significantly improve. The number of park visitors observed increased by 53% and 50%, respectively. Both parks had increased usage during evening hours when the family programming was the greatest. This study has several implications for policy and practice. First, this study suggests that community engagement can play a role in redesigning a park and likely leads to increased awareness and use of neighborhood parks. Second, while park use increased, simply adding new features to a park may not immediately increase physical activity. Additional efforts need to be made to activate the park and increase physical activity. Third, practitioners should not discount the value of building park awareness that increases park use as it may be a first step to increasing physical activity.

Results of an Initiative Supporting Community-Based Organizations and Health Care Clinics to Assist Individuals With Enrolling in SNAP.

CONTEXT: Only 58% of eligible Coloradans are enrolled in the Supplemental Nutrition Assistance Program (SNAP). In recent years, more community-based organizations (CBOs) and health care clinics are incorporating screening for social needs into their workflows. PROGRAM: Seven Colorado-based CBOs and 3 clinics received funding (2016-2018) to screen for food insecurity (FI) and provide SNAP application assistance to their clients and patients. IMPLEMENTATION: Funded agencies were required to implement strategies focused on particular populations or settings based on Food Research and Action Center recommendations. EVALUATION: A 5-part care cascade from screening to SNAP enrollment was conceptualized to guide the evaluation. Funded CBOs and clinics were asked to submit de-identified individual-level data to the evaluation team (number and characteristics of individuals screened, screening results, interest in receiving assistance, submitted application, enrolled in SNAP). The purpose of the evaluation was to assess the proportion of individuals CBOs and clinics screen for FI and assist with completing a SNAP application and describe the characteristics of individuals who are not interested in receiving assistance to complete a SNAP application and the characteristics of individuals who enroll in SNAP. RESULTS: Thirty-five percent of individuals who reported FI participated in the care cascade and enrolled in SNAP. CBOs assisted a greater proportion of food-insecure individuals (55%) than clinics (22%) (P < .001). Males, adults 40 years or older, rural residents, and African Americans were more likely to be interested in receiving assistance, and adults 40 years or older, rural residents, and American Indians/Alaska Natives were more likely to enroll in SNAP. DISCUSSION: CBOs were more successful in assisting individuals along the care cascade than clinics. Certain subpopulations are more likely to be interested in receiving assistance and enrolling in SNAP. These findings can be used by public health practitioners to plan interventions to increase enrollment in SNAP.

Practice-Based Evidence Supporting Healthy Eating and Active Living Policy and Environmental Changes.

CONTEXT: Policy and environmental strategies have been recommended as evidence-based strategies to improve opportunities for healthy eating and active living. PROGRAM: A cohort of 6 coalitions in Colorado representing 5 communities was funded to implement policy and environmental strategies that support healthy eating and active living. Coalitions prioritized built environment to support active living and healthy food and beverage strategies. IMPLEMENTATION: Built environment coalitions prioritized the adoption of policies and implementation of infrastructure enhancements to improve access to walking, biking, and other physical activity at the institutional, regional, county, and/or municipal levels. Healthy food and beverage coalitions aimed to support the consumption of healthy foods and beverages in government settings, hospitals, and other public venues via policy, practice, or procedural changes. EVALUATION: Built environment coalitions implemented change at 61 sites by implementing 16 policies and plans and 44 environmental changes. Healthy food and beverage coalitions implemented changes at 66 sites by passing 31 policies and plans and 44 environmental and practice changes. It is estimated that more than 70 000 individuals were likely exposed to these policy and environmental changes. DISCUSSION: All community coalitions were successful in driving policy and environmental changes to promote healthy eating and active living. This program contributes to the practice-based evidence to demonstrate that with funding and resources, local public health coalitions and practitioners can drive policy and environmental changes in their communities. Providing funding to a dedicated coalition or group of partners can give coalitions the resources they need to drive these changes.

Weight Loss Disparities Among Hispanic and Underserved Participants, Colorado, 2015-2018.

INTRODUCTION: The National Diabetes Prevention Program (DPP) is an evidence-based strategy to prevent the development of type 2 diabetes in adults at high risk through education and behavior modifications that promote weight loss. This evaluation aimed to determine if National DPP participants' weight-related outcomes varied across demographic subgroups, including sex, age, race/ethnicity, and insurance status, after controlling for program attendance and physical activity. METHODS: Our cross-site evaluation used participant-level data from 11 organizations during July 2015 through June 2018. A modified Poisson regression model was used to examine the relationship between demographic subgroups, controlling for physical activity (minutes per week) and program attendance. RESULTS: A total of 1,007 National DPP participants were included in the analyzed sample. Participants lost an average of 4% of their initial body weight, approximately 8 pounds. About one-third of participants achieved greater than 5% weight loss. In the unadjusted estimates, participants who were Hispanic, non-Hispanic Black, young, and uninsured were significantly less likely to achieve 5% or greater weight loss. Demographic differences in achieving 5% or greater weight loss, however, were not significant after adjusting for program attendance and physical activity level. CONCLUSIONS: Disparities in National DPP weight-related outcomes were not observed across demographic groups after adjusting for program attendance and physical activity levels. However, non-Hispanic Black participants had lower attendance and Hispanic participants reported less physical activity than participants of other races/ethnicities. Strategies to improve National DPP participation and increase physical activity, therefore, should be prioritized among Hispanic and non-Hispanic Black participants.

Increasing Physical Activity in Schools: Strategies for School Health Practitioners.

Background. Colorado passed House Bill 11-1069 in 2011 requiring all public elementary schools to provide students with a minimum of 30 minutes of physical activity (PA) per school day (Physical Activity Expectation in Schools, 2011). The purpose of this article is to describe the results of a 3-year initiative to increase opportunities for PA and to provide recommendations for school health practitioners implementing similar programming. Intervention. In 2014, 13 school districts were funded to increase student PA during school hours and before and after school hours. Intervention activities spanned all components of the Comprehensive School Physical Activity Program framework. An evaluation was conducted to estimate the number of schools providing at least 30 minutes of PA a day. A mixed methods evaluation design was implemented that included tracking the number of minutes of PA provided before, during, and after school and semistructured interviews with school health coordinators. Results. In Year 1, an average of 48 minutes of PA were provided per day. By the end of year 3, the average minutes of PA doubled to 90 minutes per day. Teachers and staff identified professional development and administrator support as key components to incorporating more PA throughout the school day. Conclusions. Health promotion interventions in schools can increase access to PA opportunities for students. Sustainability of PA efforts in schools is dependent on funding to support professional development for teachers and staff and building administrative support for school-based PA.

An Evaluation of an Unstructured and Structured Approach to Increasing Recess Physical Activity.

BACKGROUND: The purpose of this study was to evaluate an unstructured and a structured program designed to increase physical activity (PA). The unstructured program increased the amount of equipment during recess, whereas the structured program introduced activities to students. METHODS: PA was observed using the System for Observing Play and Leisure Activity in Youth (SOPLAY) in two school districts in Colorado. Researchers recorded baseline and follow-up observations for sedentary activity, moderate PA, and vigorous PA, as well as for available equipment for the unstructured program. Observations from schools were aggregated for data analyses at the district level. RESULTS: For the program increasing equipment, moderate PA and vigorous PA increased, while sedentary behavior decreased. For the structured program, moderate PA and vigorous PA did not increase, whereas sedentary behaviors increased following the program. CONCLUSIONS: Other variables are likely influencing student PA during recess, such as teachers' interaction with students or the fidelity of the program. Results indicate that funding and implementing a program aimed at increasing PA will not necessarily accomplish that goal, and additional research should be performed to determine the best practice for increasing PA.

Using Population Dose to Evaluate Community-level Health Initiatives.

Successful community-level health initiatives require implementing an effective portfolio of strategies and understanding their impact on population health. These factors are complicated by the heterogeneity of overlapping multicomponent strategies and availability of population-level data that align with the initiatives. To address these complexities, the population dose methodology was developed for planning and evaluating multicomponent community initiatives. Building on the population dose methodology previously developed, this paper operationalizes dose estimates of one initiative targeting youth physical activity as part of the Kaiser Permanente Community Health Initiative, a multicomponent community-level obesity prevention initiative. The technical details needed to operationalize the population dose method are explained, and the use of population dose as an interim proxy for population-level survey data is introduced. The alignment of the estimated impact from strategy-level data analysis using the dose methodology and the data from the population-level survey suggest that dose is useful for conducting real-time evaluation of multiple heterogeneous strategies, and as a viable proxy for existing population-level surveys when robust strategy-level evaluation data are collected. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

Colorado Healthy Eating and Active Living Cities and Towns Campaign.

The goal of the Healthy Eating/Active Living (HEAL) Cities and Towns Campaign is to provide municipal leaders with the information, tools, and personalized assistance they need to promote and adopt policies that advance population health. Colorado is composed of 271 cities and towns and has one of the fastest-growing obesity rates in the nation. Colorado's Campaign began in 2012 with a partnership between LiveWell Colorado and the Colorado Municipal League. As a grantee of a regional public health organization, the Campaign Coordinator provides technical assistance to municipal leaders and recognizes cities and towns that adopt varied HEAL policies with four designations: Eager, Active, Fit, and Elite. These designations are based on the total number of policies the municipality currently has and how many they are willing to adopt to move up in status, ranging from Eager (working on one policy) to Elite (at least five policies adopted). Since 2012, there have been 50 Colorado cities and towns that have joined the Campaign reaching more than 2.9 million Colorado residents (more than 50% of the population). Sixteen percent of Colorado's population lives in a city or town with at least five HEAL policies. The purpose of this special article is to describe how the Campaign in Colorado uses tailored technical assistance to help municipalities adopt HEAL-related policies and share some lessons learned for other public health organizations working on similar campaigns. SUPPLEMENT INFORMATION: This article is part of a supplement entitled Building Thriving Communities Through Comprehensive Community Health Initiatives, which is sponsored by Kaiser Permanente, Community Health.

A Method for Evaluating Physical Activity Programs in Schools.

Providing opportunities for students to be physically active during the school day leads to increased academic performance, better focus, and fewer behavioral problems. As schools begin to incorporate more physical activity programming into the school day, evaluators need methods to measure how much physical activity students are being offered through this programming. Because classroom-based physical activity is often offered in 3-minute to 5-minute bouts at various times of the day, depending on the teachers' time to incorporate it, it is a challenge to evaluate this activity. This article describes a method to estimate the number of physical activity minutes provided before, during, and after school. The web-based tool can be used to gather data cost-effectively from a large number of schools. Strategies to increase teacher response rates and assess intensity of activity should be explored.

Intensity of commonly-reported classroom-based physical activity opportunities in public schools.

The purpose of this study was to examine the intensity levels of PA opportunities offered in public school classrooms. Schools (N = 101) in school districts (N = 25) reported PA opportunities offered in classrooms using an online data collection tool over a two-year period (2014-2016). Using a randomized sampling technique, 20-30% of teachers in each school were selected each week to report PA in their classroom. These responses resulted in N = 18,210 usable responses. A researcher determined the intensity of PA opportunities using the 2011 Compendium of Physical Activities as a guideline; two additional researchers confirmed the coded categories. A descriptive analysis of PA opportunities was conducted to describe the proportion of opportunities whose intensity levels were light (LPA), moderate (MPA), vigorous (VPA), sedentary (SED), and those of unknown intensity. Chi-square analyses were utilized to examine differences between proportions of intensity levels offered by semester. Kruskal-Wallace tests were utilized to examine differences in proportion of physical activity opportunity intensity offered by grade level. Most PA opportunities were MPA (58.7%), followed by VPA (17.6%) and LPA (11.5%). Few responses were SED (0.5%), and 11.6% were of indeterminate intensity. A greater proportion of more physically intense activities reported during the fall versus spring semesters (p < 0.0001). Differences in the intensity levels of PA offered by grade also differed, with a trend of decreasing intensity as grade level increased (p < 0.0001). This study provides insight into the PA actually occurring in classrooms; a previously underexplored construct of school-based PA.

A Profile of Active Transportation in Colorado Public Schools, 2014-2015.

Active transportation (AT) may represent an ideal opportunity to accumulate physical activity (PA). Thus, the purpose of this study was to describe the AT profile among students from two Colorado school districts. Students completed a survey on AT resulting in a final dataset (n = 3738) from which descriptive and inferential statics were calculated. Respondents were 11.32 ± 2.82 years of age (Boys = 48.27 %; Girls = 51.73 %). Most students (87.29 %) traveled to or from school via automobile, while 11.17 % walked and 1.53 % biked. Boys rode bicycles to school significantly more (p < 0.0001) than girls, and when walking, accumulated significantly more time (p = 0.02) than females. When examining by grade level significant differences were found for days/week walking (p = 0.0002) to school and biking (p < 0.001) to school. High school students accumulated significantly (p < 0.0001) more time walking to school than middle or elementary school students. Similarly, high school students spent more time biking (p < 0.0001) to school than middle school and elementary school respondents. These findings indicate that travel to school by automobile is still the dominant mode of travel for most public school students. Further, males were generally more likely to obtain extra time in AT. Moreover, older students were more likely to engage in AT, and to spend more time during their AT.

Walking to Work: The Roles of Neighborhood Walkability and Socioeconomic Deprivation.

BACKGROUND: There are few studies that aimed to find a relationship between transportation-related physical activity and neighborhood socioeconomic condition using a composite deprivation index. The purpose of this study is to assess the relationship of neighborhood walkability and socioeconomic deprivation with percentage of adults walking to work. METHODS: A walkability index and a socioeconomic deprivation index were created at block group-level. The outcome variable, percentage of adults who walk to work was dichotomized as < 5% of the block group walking to work low and ≥ 5% of the block group walking to work as high and applied logistic regression to examine the association of walkability and socioeconomic deprivation with walking to work. RESULTS: Individuals in the most walkable neighborhoods are almost 5 times more likely to walk to work than individuals in the least walkable neighborhoods (OR = 4.90, 95% CI = 2.80-8.59). After adjusting for neighborhood socioeconomic deprivation, individuals in the most walkable neighborhoods are almost 3 times more likely to walk to work than individuals in the least walkable neighborhoods (OR = 2.98, 95% CI = 1.62-5.49). CONCLUSIONS: Walkability (as measured by the walkability index) is a very strong indicator of walking to work even after controlling for neighborhood socioeconomic disadvantage.

The built environment predicts observed physical activity.

BACKGROUND: In order to improve our understanding of the relationship between the built environment and physical activity, it is important to identify associations between specific geographic characteristics and physical activity behaviors. PURPOSE: Examine relationships between observed physical activity behavior and measures of the built environment collected on 291 street segments in Indianapolis and St. Louis. METHODS: Street segments were selected using a stratified geographic sampling design to ensure representation of neighborhoods with different land use and socioeconomic characteristics. Characteristics of the built environment on-street segments were audited using two methods: in-person field audits and audits based on interpretation of Google Street View imagery with each method blinded to results from the other. Segments were dichotomized as having a particular characteristic (e.g., sidewalk present or not) based on the two auditing methods separately. Counts of individuals engaged in different forms of physical activity on each segment were assessed using direct observation. Non-parametric statistics were used to compare counts of physically active individuals on each segment with built environment characteristic. RESULTS: Counts of individuals engaged in physical activity were significantly higher on segments with mixed land use or all non-residential land use, and on segments with pedestrian infrastructure (e.g., crosswalks and sidewalks) and public transit. CONCLUSION: Several micro-level built environment characteristics were associated with physical activity. These data provide support for theories that suggest changing the built environment and related policies may encourage more physical activity.

A method for building evaluation competency among community-based organizations.

Community-based organizations often lack the capacity (e.g., time, staff, skills) to effectively evaluate programs, policies, and environmental changes. Providing evaluation technical assistance and training can be an effective and feasible way to build individual evaluation competency. The purpose of this article is to present a practical approach and related tools that can be used by evaluators and others (e.g., academic partners, funders) providing assistance to build evaluation skills in community organizations. The approach described was developed in collaboration with local universities and a regional health foundation to provide intensive technical support to 19 community-based organizations awarded funding to implement obesity prevention projects. Technical assistance processes and tools were designed to be tailored to organizations' capacity and needs and can be used as templates by others who provide technical assistance. Evaluators, funders, and academic partners can use lessons learned from this experience to help shape and implement evaluation technical assistance approaches with community-based organizations.