"Doubling Up" on Produce at Detroit Farmers Markets: Patterns and Correlates of Use of a Healthy Food Incentive.

INTRODUCTION: Federal food assistance programs such as the Supplemental Nutrition Assistance Program (SNAP) help address food insecurity, yet many participants still struggle to afford nutritionally adequate foods. The U.S. Department of Agriculture has committed $100 million to the expansion and evaluation of SNAP healthy food incentives, which match SNAP funds spent on produce. However, little is known about who uses SNAP incentives or how often they are used. This study examines patterns and correlates of use of the SNAP incentive Double Up Food Bucks at all eight participating Detroit farmers markets during 2012-2013. METHODS: SNAP/Double Up Food Bucks transactions from handwritten farmers market logs (n=21,541) were linked with state administrative SNAP enrollment data. Frequency of incentive use and characteristics of Double Up Food Bucks users relative to the overall Detroit SNAP-enrolled population were examined, as were market-level characteristics associated with program use. Negative binomial regression was used to estimate predictors of repeat transactions (analyses conducted 2015-2017). RESULTS: Although demographic characteristics of Double Up Food Bucks users reflected those of the overall Detroit SNAP-enrolled population, Double Up Food Bucks users were poorer and disproportionately female. One third of Double Up Food Bucks users had more than one transaction during the 2-year period. Repeat transactions were directly correlated with identifying as white (incidence rate ratio=2.34, 95% CI=2.11, 2.59, p<0.001), and inversely correlated with driving distance from market of first transaction (incidence rate ratio=0.98 per mile, 95% CI=0.98, 0.99, p<0.001). Rates of repeat transactions also varied significantly by market. CONCLUSIONS: Addressing barriers to initial use and return visits can help maximize the impact and reach of SNAP incentives among Americans at highest risk of diet-related disease.

Clinic and Community: The Road to Integration.

INTRODUCTION: There is growing recognition of the important role that social and environmental conditions play in health, and of the interaction needed between clinical providers and the broader community in which patients live, work, play, and manage their health. Through the Safety Net Enhancement Initiative, the Kresge Foundation funded demonstration projects in eight vulnerable communities to address health inequities and increase integration between clinical and community systems. METHODS: In 2014, integration efforts in 2011-2013 were qualitatively analyzed within and between sites to identify common features. The series of steps taken by sites during the 3-year implementation period that were necessary to move toward integration were then analyzed. RESULTS: Safety Net Enhancement Initiative sites increased capacities within clinics, including policy and practice changes that expanded the way "health" is defined by clinical providers and the implementation of onsite programs/services. Several sites changed clinic policies to support referral to community programs with partner organizations. Several sites also successfully changed local community policies and practices. Moving toward integration, mechanisms were created to link newly developed or identified community resources to the clinical system. CONCLUSIONS: As an established system organized around disease treatment, not prevention, certain changes need to be made within the clinical system to prepare for integration. These changes require shifting perspectives, changing behaviors, and developing novel administrative models. Similarly, integration requires changes within and among community systems, including organizations, services, and residents. Ultimately, there is the need to find ways for these two very different environments to interact and coordinate.

Improvements in health care use associated with community coalitions: long-term results of the allies against asthma initiative.

OBJECTIVES: We assessed changes in asthma-related health care use by low-income children in communities across the country where 6 Allies Against Asthma coalitions (Hampton Roads, VA; Washington, DC; Milwaukee, WI; King County/Seattle, WA; Long Beach, CA; and Philadelphia, PA) mobilized stakeholders to bring about policy changes conducive to asthma control. METHODS: Allies intervention zip codes were matched with comparison communities by median household income, asthma prevalence, total population size, and race/ethnicity. Five years of data provided by the Center for Medicare and Medicaid Services on hospitalizations, emergency department (ED) use, and physician urgent care visits for children were analyzed. Intervention and comparison sites were compared with a stratified recurrent event analysis using a Cox proportional hazard model. RESULTS: In most of the assessment years, children in Allies communities were significantly less likely (P < .04) to have an asthma-related hospitalization, ED visit, or urgent care visit than children in comparison communities. During the entire period, children in Allies communities were significantly less likely (P < .02) to have such health care use. CONCLUSIONS: Mobilizing a diverse group of stakeholders, and focusing on policy and system changes generated significant reductions in health care use for asthma in vulnerable communities.

Multilevel correlates of satisfaction with neighborhood availability of fresh fruits and vegetables.

BACKGROUND: Little is known about influences on perceptions of neighborhood food environments, despite their relevance for food-shopping behaviors and food choices. PURPOSE: This study examined relationships between multilevel factors (neighborhood structure, independently observed neighborhood food environment, and individual socioeconomic position) and satisfaction with neighborhood availability of fruits and vegetables. METHODS: The multilevel regression analysis drew on data from a community survey of urban adults, in-person audit and mapping of food stores, and the 2000 Census. RESULTS: Satisfaction with neighborhood availability of fruits and vegetables was lower in neighborhoods that were farther from a supermarket and that had proportionately more African-American residents. Neighborhood poverty and independently observed neighborhood fruit and vegetable characteristics (variety, prices, and quality) were not associated with satisfaction. Individual education modified relationships between neighborhood availability of smaller food stores (small grocery stores, convenience stores, and liquor stores) and satisfaction. CONCLUSIONS: Individual-level and neighborhood-level factors affect perceptions of neighborhood food environments.

Delphi-derived development of a common core for measuring complementary and alternative medicine prevalence.

Assessing complementary and alternative medicine (CAM) use remains difficult due to many problems, not the least of which is defining therapies and modalities that should be considered as CAM. Members of the International Society for Complementary Medicine Research (ISCMR) participated in a Delphi process to identify a core listing of common CAM therapies presently in use in Western countries. Lists of practitioner-based and self-administered CAM were constructed based on previous population-based surveys and ranked by ISCMR researchers by perceived level of importance. A total of 64 (49%) ISCMR members responded to the first round of the Delphi process, and 39 of these (61%) responded during the second round. There was agreement across all geographic regions (United States, United Kingdom, Canada, and Western Europe) for the inclusion of herbal medicine, acupuncture, homeopathy, Traditional Chinese Medicine (TCM), chiropractic, naturopathy, osteopathy, Ayurvedic medicine, and massage therapy in the core practitioner-based CAM list, and for homeopathy products, herbal supplements, TCM products, naturopathic products, and nutritional products in the self-administered list. This Delphi process, along with the existing literature, has demonstrated that (1) separate lists are required to measure practitioner-based and self-administered CAM; (2) timeframes should include both ever use and recent use; (3) researchers should measure and report prevalence estimates for each individual therapy so that direct comparisons can be made across studies, time, and populations; (4) the list of CAM therapies should include a core list and additionally those therapies appropriate to the geographic region, population, and the specific research questions addressed, and (5) intended populations and samples studied should be defined by the researcher so that the generalizability of findings can be assessed. Ultimately, it is important to find out what CAM modality people are using and if they are being helped by these interventions.

Neighborhood retail food environment and fruit and vegetable intake in a multiethnic urban population.

PURPOSE: To examine relationships between the neighborhood food environment and fruit and vegetable intake in a multiethnic urban population. DESIGN: Analysis of cross-sectional survey and observational data. SETTING: One hundred forty-six neighborhoods within three large geographic communities of Detroit, Michigan. SUBJECTS: Probability sample of 919 African-American, Latino, and white adults. MEASURES: The dependent variable was mean daily fruit and vegetable servings, as measured by using a modified Block 98 food frequency questionnaire. Independent variables included the neighborhood food environment: store availability (i.e., large grocery, specialty, convenience, liquor, small grocery), supermarket proximity (i.e., street-network distance to nearest chain grocer), and perceived and observed neighborhood fresh fruit and vegetable supply (i.e., availability, variety, quality, affordability). ANALYSIS: Weighted, multilevel regression. RESULTS: Presence of a large grocery store in the neighborhood was associated with, on average, 0.69 more daily fruit and vegetable servings in the full sample. Relationships between the food environment and fruit and vegetable intake did not differ between whites and African-Americans. However, Latinos, compared with African-Americans, who had a large grocery store in the neighborhood consumed 2.20 more daily servings of fruits and vegetables. Presence of a convenience store in the neighborhood was associated with 1.84 fewer daily fruit and vegetable servings among Latinos than among African-Americans. CONCLUSION: The neighborhood food environment influences fruit and vegetable intake, and the size of this relationship may vary for different racial/ethnic subpopulations.

Community coalitions to control chronic disease: Allies against asthma as a model and case study.

There is a rich and extensive literature regarding coalitions as vehicles for amassing resources, influence, and energy in pursuit of a health goal. Despite insufficient empirical data regarding outcome, a number of observers have posited the aspects of coalition processes thought to lead to goal attainment. The supplement, which this article is part of, is devoted to an examination of how these elements fitted together (or did not) in the seven areas across the United States where Allies coalitions devoted themselves to achieving asthma control. The aim of this article is to present the theoretical bases for the work of the coalitions. It illustrates and emphasizes how the community context influenced coalition development, how membership was involved in and assessed coalition processes and structures, and the community-wide actions that were instituted and the capacities they were trying to strengthen.

Building allies coalitions: Why formation matters.

This article describes how formation of the Allies Against Asthma coalitions was influenced by community context, history, leadership, membership, structure, processes, and other factors. Based on member surveys, key informant interviews, and self-assessment tools, results indicate that three coalitions developed from existing coalitions, and four formed in response to funding. The coalitions took an average of 12 months to form and completed 98% of formation tasks. Funding, technical support, and networking among grantees promoted formation. Although cultures, geographies, lead agencies, and years of experience differed, coalitions developed similar structures and processes. Two of three new coalitions took the longest to form, highlighting the need for flexibility and technical assistance when funding new coalitions.

From formation to action: How allies against asthma coalitions are getting the job done.

Coalitions develop in and recycle through stages. At each stage (formation, implementation, maintenance, and institutionalization), certain factors enhance coalition function, accomplishment of tasks, and progression to the next stage. The Allies Against Asthma coalitions assessed stages of development through annual member surveys, key informant interviews of 16 leaders from each site, and other evaluation tools. Results indicate all coalitions completed formation and implementation, six achieved maintenance, and five are in the institutionalization stage. Differences among coalitions can be attributed to their maturity and experience working within a coalition framework. Participants agreed that community mobilization around asthma would not have happened without coalitions. They attributed success to being responsive to community needs and developing comprehensive strategies, and they believed that partners' goals were more innovative and achievable than any institution could have created alone.

Collaborative design and implementation of a multisite community coalition evaluation.

Evaluation designs assessing community coalitions must balance measures of how coalitions do their work and evidence that the coalitions are making a difference. The Allies cross-site evaluation attempts to determine the combined effects of the seven coalitions' work at the individual, organizational, and community levels. Principal components considered are (a) contextual factors of the coalition community, (b) coalition processes and structure, (c) planning and planning products, (d) implementation actions, (e) activities and collaborations, (f) anticipated intermediate outcomes, and (g) expected asthma related health outcomes. Measurements are quantitative and qualitative, and data generated by these methods are used as ends in themselves and as a way to confirm or inform other measures. Evaluation has been an integral part of the planning and implementation phases of the Allies coalition work, with a priority of involving all of the partners in conceiving of and deciding upon the elements of assessment.

Engaging the community in coalition efforts to address childhood asthma.

For health improvement efforts to effectively address community needs, community members must be engaged in planning and implementing public health initiatives. For Allies Against Asthma's coalitions, the community included not only the subpopulation of individuals who suffer disproportionately from asthma but also the individuals and institutions that surround them. Through a quantitative self-assessment survey, informal discussion among coalition leadership, and interviews with key informants, data relevant to community engagement identified a number of important ways the Allies coalitions approached community involvement. Respondents' comments made clear that the way the coalitions conduct their work is often as important as what they do. Across coalitions, factors that were identified as important for community involvement included (a) establishing a commitment to community involvement, (b) building trust, (c) making participation feasible and comfortable, (d) responding to community identified needs, (e) providing leadership development opportunities, and (f) building a shared commitment to desired outcomes.

Engaging health care providers in coalition activities.

Health care providers play a key role in promoting and participating in asthma coalition activities. Barriers to participation include lack of time, concern about coalition effectiveness, and unfamiliarity with community-based approaches to health issues. Despite this, the Allies Against Asthma coalitions were successful at involving health care providers in leadership roles, on advisory committees, and as research and clinical experts. Successful engagement strategies included presentation of data illustrating need for improved asthma care, identification of clinicians who were involved in caring for children with uncontrolled asthma, and education regarding the added value of a coalition and benefits of participation. Despite barriers to participation, health care providers felt that their participation in asthma coalitions helped them to develop collaborative relationships with other agencies, increase their professional knowledge and skills with regard to asthma management, and improve access to priority populations.

Childhood asthma surveillance by community coalitions.

Multiple benefits can accrue when community coalitions conduct asthma surveillance activities. Surveillance data are used to identify children with asthma, assess disease burden and needs in the community, understand the illness and risk factors, identify children with asthma who are undertreated, plan community interventions, evaluate the effect of interventions, and monitor trends. These data, which are used to inform coalition and program decisions and to evaluate asthma interventions, can also be used to strengthen state and national asthma surveillance efforts and to inform clinical practice and public health policies. Local coalition data collection represents a complementary approach to national asthma surveillance, allowing action at the local level and showing how local findings vary from national observations. The Allies Against Asthma coalitions developed several practical means to conduct childhood asthma surveillance that informed coalition efforts and facilitated innovative linkages among government officials, health care providers, community agencies, families, and academicians and/or researchers.

Improving quality of care and promoting health care system change: The role of community-based coalitions.

As part of their community action plans, the Allies Against Asthma coalitions have developed efforts to improve quality of care and promote health care system change. All the coalitions have used an interdisciplinary collaborative approach to design these strategies and demonstrated a range of intervention approaches appropriate to their local context and circumstances. The coalitions' collective experience suggests that coalitions provide three key forces for quality improvement and change that may be lacking in the current fragmented U.S. health care system--motivation to change the status quo, integration across systems, and accountability for results. The collaborative and empowering processes that a coalition model encourages and the direct advocacy opportunity provided to the consumer appear to bring these forces into play.

Integrating asthma prevention and control: the roles of the coalition.

Activities addressing pediatric asthma are often fragmented. Allies coalitions promoted integration, the alignment of concurrent asthma control activities across and within sectors. Systems integration describes activities from an organizational perspective. Activities included developing a shared vision, promoting consistency in asthma education and self-management support, improving adherence to clinical guidelines, advocating jointly for policy change, and seeking funds collaboratively. Service integration describes activities focused on ensuring seamless, comprehensive services through coordination within and across organizations. Activities included use of community health workers (CHWs) and nurses for care coordination, program cross-referral, and clinical quality improvement. Integration is a sustainable role for coalitions as it requires fewer resources than service delivery and results in institutionalization of system changes. Organizations that seek integration of asthma control may benefit.

Osteoarthritis of the knee: comparison of MR imaging findings with radiographic severity measurements and pain in middle-aged women.

PURPOSE: To prospectively compare magnetic resonance (MR) imaging-defined abnormalities of osteoarthritis (OA) of the knee with radiographic severity measurements of OA of the knee and self-reported pain. MATERIALS AND METHODS: This study was approved by the institutional review board of University of Michigan. Informed consent was obtained for this HIPAA-compliant study. Knee MR imaging was performed in 117 women (mean age, 46 years; range, 32-56 years) from a community-based arthritis study (n = 1053) with 30 women in each of four categories: (a) no pain and no OA of the knee, (b) no pain and OA of the knee, (c) pain and no OA of the knee, and (d) pain and OA of the knee. OA of the knee was defined from radiographs. Two hundred thirty-two eligible knees had Kellgren-Lawrence scores for OA of the knee as follows: grade 0, 115 (49.6%); grade 1, 33 (14.2%); grade 2, 66 (28.4%); grade 3, 17 (7.3%); and grade 4, one (0.4%). MR images were assessed for location and severity of defects of cartilage, bone marrow edema (BME), osteophytes, subchondral cysts, sclerosis, meniscal and/or ligamentous tears, joint effusion, synovial cysts, and synovitis. MR imaging findings were compared with radiographic severity of OA of the knee (Kellgren-Lawrence scale) and self-reported pain with analysis of variance, t tests, and contingency table analyses. RESULTS: Defects of cartilage (higher than grade IIA) were found in 75% of knees; BME was found in 57% of knees (<1 cm, 41%; >1 cm, 16%). Large BME lesions were common in the pain and OA of the knee group (P = .001); this group was significantly more likely to have defects of cartilage (P = .001); meniscal tears (P = .001); and osteophytes, subchondral cysts, sclerosis, joint effusion, and synovitis (P < .001). Defects of cartilage, osteophytes, sclerosis, meniscal or ligamentous tears, joint effusion, and synovitis were strongly related to increasing Kellgren-Lawrence grade (P < .001). CONCLUSION: In middle-aged women, there were significant associations between pain, radiographic severity of OA of the knee, and seven MR imaging-identified parameters.