Legislative Health Notes: Preliminary Learnings From Piloting a New Policy Analysis Tool.

CONTEXT: In 2018, the Health Impact Project (the Project) developed and tested a new health in all policies (HiAP) tool called "legislative health notes" to provide state and local legislators with peer-reviewed evidence, public health data, and local data that illustrate potential positive and negative health and equity effects of proposed bills. OBJECTIVES: The Project sought to refine the health note methodology while piloting the tool in the Colorado and Indiana General Assemblies, and with the Council of the District of Columbia, and worked with affiliates to introduce them in North Carolina, Ohio, and California. DESIGN AND PARTICIPANTS: External partners solicited feedback on health notes via semistructured interviews and surveys from legislators, legislative staff, and expert reviewers who were familiar with health notes in each of these jurisdictions. RESULTS: Respondents shared that health notes were nonpartisan, were easy for nonexperts to understand, and would be more effective if delivered earlier in the legislative process. CONCLUSION: In response to informant feedback, practitioners can explore adding high-level summaries, increasing focus on health equity implications and the potential to work with legislators during the policy formulation phase. Data from this pilot suggest that legislative health notes are a promising nonpartisan and standardized tool to better understand the health and equity implications of proposed legislation.

Structural and relational factors for successful cross-sector collaboration in home visiting: a multiple case study.

BACKGROUND: Aligning delivery and financing systems across sectors to create broader systems of care can improve the health and well-being of families experiencing adversities. We aimed to identify structural and relational factors for best practices to achieve successful cross-sector collaboration among home visiting programs in the United States. MATERIALS AND METHODS: We used a multiple case study approach to identify best practices for successful cross-sector collaboration between home visitors and other community service providers. We selected five diverse exemplary cases with cross-sector collaboration with variation in implementing agency type and geographic location. Cases were selected using a positive deviance approach based on strong coordination and integration with different community service provider types identified from previous survey data. We conducted in-depth qualitative interviews with home visiting staff, community providers, and clients with a total of 76 interviews conducted from 2021 to 2022. We wrote memos to synthesize themes within each case through data triangulation using interview data, documents, and site visit observations. We compared themes across the five cases to create a cross-case synthesis of best practices for successful cross-sector collaboration. RESULTS: Across the five cases, relational factors including leadership from all levels, champions across sectors, and shared goals between community providers were key factors for successful collaboration. Interpersonal relationships, coupled with the desire and capacity to engage, facilitated effective coordination to address families' needs. At the structural level, shared data systems, written agreements, and co-location enabled care coordination activities. Community Advisory Boards provided a venue for developing partnerships, relationship-building, resource-sharing, and increasing awareness of home visiting. CONCLUSIONS: We identified key elements of successful cross-sector collaboration across five case studies where home visitors coordinate care frequently and/or are structurally integrated with a range of providers. These learnings will inform future interventions to improve home visiting collaboration with other community providers to create a system of care to enhance family well-being.

Comparison of hospital claims and poison center data to evaluate health impact of opioids, cannabis and synthetic cannabinoids.

INTRODUCTION: Over the past 10 years, opioids and cannabis have garnered significant attention due to misuse and legalization trends. Different datasets and surveillance mechanisms can lead to different conclusions the due to a variety of factors. The primary objective of this study was to compare and describe trends of opioid, cannabis, and synthetic cannabinoid-related healthcare encounters and poison center (PC) cases in Colorado, a state that has legalized cannabis. METHODS: This was a retrospective study comparing hospital claims data (Colorado Hospital Association (CHA)) and poison center cases to describe opioid, cannabis and synthetic cannabinoid-related healthcare encounters and exposures in Colorado from 2013 to 2017 using related genetic codes and International Statistical Classification of Disease codes. RESULTS: Both datasets observed increases in cannabis related encounters and exposures after recreational cannabis legalization in 2014. CHA reported an increase for cannabis-related ER visits from 14,109 in 2013 to 18,118 in 2017 while PC noted a 74.4% increase in cannabis-related cases (125 to 218). CHA inpatient visits associated with cannabis also increased (8311 in 2013 to 14,659 in 2017). On the other hand, Opioid-related exposures to the PC fell (1092 in 2013 to 971 in 2017) while both Opioid-related ER visits (8580 in 2013 to 12,928 in 2017) and inpatient visits in CHA increased (9084 in 2013 to 13,205). CONCLUSIONS: This study demonstrates the differences in surveillance methodology for concurrent drug abuse epidemics using hospital claims and PC data. Both systems provide incomplete reports, but in combination can provide a more complete picture.

APCDs can Provide Important Insights for Surveilling the Opioid Epidemic, With Caveats.

State-level all-payer claims databases (APCDs) are a possible new public health surveillance tool, but their reliability is unclear. We compared Colorado's APCD with other state-level databases for use in monitoring the opioid epidemic (Colorado Hospital Association and Colorado's Prescription Drug Monitoring Program database for 2010-2017), using descriptive analyses comparing quarterly counts/rates of opioid-involved inpatient and emergency department visits and counts/rates of 30-day opioid fills between databases. Utilization is lower in the Colorado APCD than the other databases for all outcomes but trends are parallel and consistent between databases. State APCDs hold promise for researchers, but they may be better suited to individual-level analyses or comparisons of providers than for surveillance of public health trends related to addiction.

A qualitative study of effective collaboration among nurse home visitors, healthcare providers and community support services in the United States.

Collaboration across sectors is needed to improve community health, but little is known about collaborative activities among public health prevention programs. Using the Nurse-Family Partnership® (NFP) home visiting program as context, this qualitative study aimed to describe effective collaboration among nurse home visitors, healthcare providers and community support services to serve families experiencing social and economic adversities. We used grounded theory to characterise collaboration with six purposively sampled NFP sites in the United States through in-depth interviews. We interviewed 73 participants between 2017 and 2019: 50 NFP staff, 18 healthcare providers and 5 other service providers. Interviews were recorded, transcribed, validated and analysed in NVivo 11. Validation steps included inter-coder consistency checks and expert review. Thematic memos were synthesised across sites. Most participants perceived collaboration to be important when serving families with complex needs, but substantial variation existed in the degree to which NFP nurses collaborate with providers dependent on provider type and community context. Factors that contributed to effective collaboration were relational in nature, including leadership commitment and provider champions, shared perceptions of trust, respect and value, and referral partnerships and outreach; organisational in terms of mission congruence between providers; and structural such as policy and system integration that facilitated data sharing and communication channels. These findings provide greater insights into effective cross-sector collaboration and care coordination for families experiencing adversities. Collaboration across sectors to promote health among families experiencing adversities requires intentional efforts by all inter-professional providers and continued commitment among all levels of leadership to coordinate services.

National survey of nurse home visitor collaboration with health care and social services.

OBJECTIVE: To assess the degree to which nurses in a national public health home visiting program collaborate with interprofessional providers to serve families experiencing adversity. DESIGN: A descriptive, cross-sectional survey measured collaborative practices between nurse home visitors, health care, and social service providers. A census of 263 nursing supervisors completed a web-based survey. MEASUREMENTS: The survey included the validated 7-item Relational Coordination Scale, adapted items from the Interagency Collaboration Activities Scale on shared resources, and items related to collaboration attitudes and beliefs. Data were analyzed with descriptive statistics. RESULTS: Relational coordination scores, which are relative measures, ranged from 1 to 5; highest with supplemental nutrition for Women, Infants & Children (M = 3.77) and early intervention (M = 3.44); and lowest with housing (M = 2.55). The greatest sharing of resources was with supplemental nutrition (sum = 12.95) and mental health providers (sum = 11.81), and least with housing (sum = 7.26); with a range of 1-30 where higher scores indicated greater resource-sharing. CONCLUSION: Home visiting nurses collaborate with interprofessional providers with variation in the degree of collaboration between agencies and by provider type within an agency. Collaboration was a function of two interrelated domains: interpersonal relationships supported by organizational and contextual factors at the systems-level.

Kids, Cops, and Community: A Qualitative Assessment of Police, Youth, and Parent Perceptions of Each Other.

CONTEXT: Police and communities alike have experienced many traumatic incidents over the last 4 years, prompting police departments across the country to rethink their approach to community programs. PROGRAM: Aurora's Gang Reduction Impact Program (A-GRIP) launched "Kids, Cops, and Community" (KC&C) in Aurora, Colorado, as a community-based quality improvement project designed to improve community relations by better understanding Aurora police and community members' perceptions of each other and current A-GRIP and Aurora for Youth programs by assessing police, youth, and parents' perceptions of each other. IMPLEMENTATION: After a review of current scientific literature on police-community relations, a KC&C advisory group oversaw the creation of key informant interview and focus group guides. A-GRIP recruited participants for 37 interviews (20 police, 8 youth, and 9 parents) and 3 youth focus groups. The community advisory group assisted in the development of salient themes and practical recommendations. The final report outlined 5 major themes (pros/cons of types of police interactions, respectful communication, false uniqueness effect, parenting and police as parents, and youth-police programming awareness) and 2 specific recommendations (sustain/increase opportunities for police-youth interactions and increase community awareness of youth programming). EVALUATION: A-GRIP members had a rich discussion of the implications of these findings in which there was broad support for identifying a strategy to use these results to improve police-community relations. The coalition was challenged by identifying clear next steps because of turnover in administration and coalition leadership, but they have made progress in increasing information and resource sharing. DISCUSSION: This project provides the first model we are aware of that incorporates a systematic assessment of police, youth, and parent perspectives from the same community. Other communities may find value in adapting the KC&C process to identify promising approaches and refine programming elements of police-community engagement activities.

Characteristics of effective collaboration: A study of Nurse-Family Partnership and child welfare.

BACKGROUND: In February 2018, President Trump signed into law the Family First Prevention Act, legislation in the United States aimed at providing prevention services for families at risk of entering the child welfare system. The effectiveness of these prevention efforts is dependent on the formation of collaborative relationships between prevention-programs and child welfare. OBJECTIVE: To identify factors that influence the ability of the Nurse-Family Partnership (NFP) and Child Protective Services (CPS) to collaborate in serving high-risk mothers and their children. PARTICIPANTS: 123 NFP, CPS workers, and community partners. SETTING: Seven sites in the U.S. state of Colorado selected to include an array of community sizes, geographies, apparent levels of collaboration, and variations in internal structures and practices. METHODS: Using an adapted grounded theory approach, we conducted semi-structured interviews with frontline NFP and CPS workers and supervisors. Interviews were recorded, transcribed, validated, and coded in NVivo 10. RESULTS: Alignment of core organizational mission and methods was key in determining collaboration levels between NFP and CPS. Only when workers perceived there to be alignment in organizational mission, did other factors such as program eligibility, communication channels, and risk and safety assessment practices influence the perceived benefits and efforts undertaken to enhance collaboration. CONCLUSIONS: High-risk families frequently require services that go beyond the scope of any one organization. As programs that serve high-risk families refine their efforts to serve them effectively, collaborative efforts should focus on examining opportunities and challenges involved in creating greater mission alignment.

State Laws and Nonprofit Hospital Community Benefit Spending.

OBJECTIVE: To determine the association of state laws on nonprofit hospital community benefit spending. DESIGN: We used multivariate models to estimate the association between different types of state-level community benefit laws and nonprofit hospital community benefit spending from tax filings. SETTING: All 50 US states. PARTICIPANTS: A total of 2421 nonprofit short-term acute care hospital organizations that filled an internal revenue service Form 990 and Schedule H for calendar during years 2009-2015. RESULTS: Between 2009 and 2015, short-term acute care hospitals spent an average of $46 billion per year in total, or $20 million per hospital on community benefit activities. Exposure to a state-level community benefit law of any type was associated with an $8.42 (95% confidence interval: 1.20-15.64) per $1000 of total operating expense greater community benefit spending. Spending amounts and patterns varied on the basis of the type of community benefit law and hospital urbanicity. CONCLUSIONS: State laws are associated with nonprofit hospital community benefit spending. Policy makers can use community benefit laws to increase nonprofit hospital engagement with public health.

Gun Retailers' Willingness to Provide Gun Storage for Suicide Prevention.

Objectives: We examined factors grounded in the theory of planned behavior that influence gun retailers' willingness to provide temporary, voluntary firearm storage for suicide prevention. Methods: We conducted a cross-sectional survey of gun retailers in the US mountain west. Analyses included descriptive statistics and ordered logistic regression. Results: Ninety-five gun retailers responded to the survey (25% response rate) and 67.6% (95% CI: 59.6, 75.6) stated that they would be very or somewhat likely to provide temporary gun storage. Firearm retailers who agreed with the statements: "Our store can be an important part of the effort to improve gun safety in my community" (OR: 1.86, 95% CI: 1.1, 3.14) and that offering storage provided "The chance to be seen as a positive member of the community" (OR: 1.49, 95% CI: 1.00, 2.22) were more likely to state that they would be willing to provide storage. Conclusions: Firearm retailers are potentially important storage partners for means safety and suicide prevention efforts. Additional research and practice innovations are needed to assess gun retailers' willingness to provide gun storage and partner on suicide prevention efforts in other geographic regions.

Gun retailers as storage partners for suicide prevention: what barriers need to be overcome?

INTRODUCTION: Safe storage of guns outside the household while someone is at risk for suicide is important for suicide prevention. Some gun retailers offer temporary firearm storage as a community resource. Others may be willing if perceived barriers can be addressed. METHODS: We invited all gun retailers in eight Mountain West states to respond to a questionnaire about the barriers they perceive in offering temporary, voluntary gun storage for community members. RESULTS: Ninety-five retailers responded (25% response rate). Fifty-eight percent believed federal laws make it harder to store guns and 25% perceived state laws to be obstacles. Over 60% cited legal liability in storing and returning guns as barriers. Other important barriers included cost, space and logistical issues of drop off and pick up. CONCLUSIONS: Strategies to reduce legal and other barriers will need to be addressed to better engage gun retailers as a community resource for safe gun storage.

Counseling Suicidal Patients About Access to Lethal Means: Attitudes of Emergency Nurse Leaders.

INTRODUCTION: For ED patients at risk of suicide, counseling to reduce access to lethal means (including firearms) is recommended yet not routine. To enhance practice uptake, we sought to examine the attitudes and beliefs of emergency nurse leaders concerning the acceptability and effectiveness of lethal-means counseling. METHODS: We invited a nurse leader (ED nurse manager or Chief Nursing Officer [CNO]) at each hospital-based emergency department in the 8-state Mountain West region of the United States to complete a closed-ended telephone survey. Questions assessed current practices and leaders' views on suicide prevention and lethal-means counseling. Reponses were weighted to all eligible hospitals to adjust for nonresponse. RESULTS: From 363 eligible hospitals, 190 emergency nurse leaders responded (overall response rate: 52%). Emergency nurse leaders thought providers at their emergency departments did an excellent job of safety counseling (74%) for suicidal patients. Most respondents believed that talking about firearms with suicidal patients is acceptable to patients (77%), supported by hospital administration (64%), effective in preventing suicide (69%), and something that providers should do (91%). However, the majority also had doubts about whether suicide is preventable (60%). DISCUSSION: Despite expressing high levels of support for the acceptability and effectiveness of lethal-means counseling, high proportions of emergency nurse leaders expressed skepticism regarding the preventability of suicide, a finding consistent with previous work. Our results support the need to address and modify misperceptions about prevention of suicide in any efforts for widespread implementation and dissemination of lethal-means counseling.

Understanding The Relationship Between Medicaid Expansions And Hospital Closures.

Decisions by states about whether to expand Medicaid under the Affordable Care Act (ACA) have implications for hospitals' financial health. We hypothesized that Medicaid expansion of eligibility for childless adults prevents hospital closures because increased Medicaid coverage for previously uninsured people reduces uncompensated care expenditures and strengthens hospitals' financial position. We tested this hypothesis using data for the period 2008-16 on hospital closures and financial performance. We found that the ACA's Medicaid expansion was associated with improved hospital financial performance and substantially lower likelihoods of closure, especially in rural markets and counties with large numbers of uninsured adults before Medicaid expansion. Future congressional efforts to reform Medicaid policy should consider the strong relationship between Medicaid coverage levels and the financial viability of hospitals. Our results imply that reverting to pre-ACA eligibility levels would lead to particularly large increases in rural hospital closures. Such closures could lead to reduced access to care and a loss of highly skilled jobs, which could have detrimental impacts on local economies.

Federal actions to incentivise state adoption of 0.08†g/dL blood alcohol concentration laws.

OBJECTIVE: To model rates of 0.08 g/dL blood alcohol concentration (BAC) per se law implementation among the states associated with (1) a federal incentive grant programme and (2) a threat from the federal government to withhold highway transportation funds. METHODS: An observational study of state-level 0.08 g/dL BAC per se law enactment among all 50 US states from 1982 to 2006 using a parametric survival analysis to assess the time-dependent risk of policy enactment. RESULTS: The federal government's threat to withhold transportation funds was associated with a 10.30 times greater hazard (HR: 10.30, 95% CI 3.88 to 27.36) of states adopting a 0.08 g/dL BAC law compared with periods of time when this threat was not in place. The incentive grant programme created by the federal government was associated with a non-significant 17% decrease in the hazard of states adopting a 0.08 g/dL BAC law (HR: 0.83, 95% CI 0.35 to 2.0). CONCLUSION: In the case of 0.08 g/dL BAC per se laws, the federal government's threat to withhold transportation funds was effective at accelerating policy adoption.

Creating smoke-free places through the UN Convention on the Rights of Persons With Disabilities.

In some high-, middle-, and low-income countries, law has been employed to limit individuals' secondhand smoke exposure. Innovative legal tools are still needed, especially in low- and middle-income countries where smoking prevalence continues to rise. For some persons with severe respiratory conditions, the presence of secondhand smoke is intolerable and prevents their entrance into restaurants and other venues. With its adoption of the Convention on the Rights of Persons with Disabilities (CRPD) in 2006, the United Nations gave countries a new way to promote the rights of disabled individuals and simultaneously address secondhand smoke exposure. We analyze the CRPD's potential to advance tobacco control goals and offer recommendations for advocates, policymakers, and others seeking to apply this approach.

Legal issues affecting children with preexisting conditions during public health emergencies.

Among the millions of children in the United States exposed to public health emergencies in recent years, those with preexisting health conditions face particular challenges. A public health emergency may, for example, disrupt treatment regimens or cause children to be separated from caregivers. Ongoing shortages of pediatricians and pediatric subspecialists may further exacerbate the risks that children with preexisting conditions face in disaster circumstances. The US Department of Homeland Security recently called for better integration of children's needs into all preparedness activities. To aid in this process, multiple legal concerns relevant to pediatricians and pediatric policymakers must be identified and addressed. Obtaining informed consent from children and parents may be particularly challenging during certain public health emergencies. States may need to invoke legal protections for children who are separated from caregivers during emergencies. Maintaining access to prescription medications may also require pediatricians to use specific legal mechanisms. In addition to practitioners, recommendations are given for policymakers to promote effective pediatric response to public health emergencies.

Legislator voting and behavioral science theory: a systematic review.

OBJECTIVES: To examine the application of behavioral science theories to explain the voting behavior of legislators for public health policies. METHODS: We conducted a systematic review to identify studies that examined factors associated with legislator support, intention to vote, or actual votes on public health policies, emphasizing those grounded in behavior science theory. RESULTS: Twenty-one papers met our inclusion criteria, and 6 were explicitly grounded in a behavioral science theory. CONCLUSIONS: Behavioral science theories, and the theory of planned behavior in particular, provide a framework for understanding legislator voting behavior and can be used by advocates to advance pro-health policies.

Interventions to reduce risks associated with vehicle incompatibility.

Occupants of smaller, lighter passenger cars are more likely to be killed or injured in collisions with larger, heavier sport utility vehicles and light trucks than in collisions with other cars. Interventions are needed to reduce this vehicle "incompatibility" and its consequences. The authors conducted a systematic literature review to identify evaluations of interventions to reduce incompatibility. They reviewed engineering, biomedical, and other technical literature. To be included, a study must have 1) evaluated an intervention to reduce vehicle incompatibility, or its consequences, in a crash; 2) reported new research; and 3) been published in English from 1990 to 2010. Seventeen studies met the inclusion criteria. Interventions were designed to reduce the aggressivity of larger vehicles or improve the crashworthiness of smaller vehicles. Effective interventions included 1) modified bumper heights, 2) improved side strength of smaller vehicles, 3) side-impact air bags, 4) changes to vehicle stiffness, and 5) modifications of other front-end structures. Some of the interventions shown to be effective are now in wide use. However, others have yet to be required by regulators or voluntarily agreed to by manufacturers. If larger, heavier vehicles remain on the nation's roads, countermeasures will be needed to reduce risks for occupants of other vehicles.

Competing initiatives: a new tobacco industry strategy to oppose statewide clean indoor air ballot measures.

To describe how the tobacco and gaming industries opposed clean indoor air voter initiatives in 2006, we analyzed media records and government and other publicly available documents and conducted interviews with knowledgeable individuals. In an attempt to avoid strict "smoke free" regulations pursued by health groups via voter initiatives in Arizona, Ohio, and Nevada, in 2006, the tobacco and gaming industries sponsored competing voter initiatives for alternative laws. Health groups succeeded in defeating the pro-tobacco competing initiatives because they were able to dispel confusion and create a head-to-head competition by associating each campaign with its respective backer and instructing voters to vote "no" on the pro-tobacco initiative in addition to voting "yes" on the health group initiative.