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1.
Healthc (Amst) ; 8 Suppl 1: 100497, 2021 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-34175103

RESUMO

BACKGROUND: Embedded Health Systems Science (HSS) has the potential to reduce gaps between research and delivery of evidence-based medicine. Models are needed to guide the development of embedded HSS in health care delivery organizations particularly with the rise of value-based care. METHODS: The development of HSS infrastructure at a large nonprofit health care delivery organization is described, along with an embedded HSS diabetes study to illustrate the integration of program specific data, electronic health records, and health care system data infrastructure. To compare diabetes outcomes across four evidenced-based programs, a control group was developed from EHR data using propensity score matching. Mixed effect adjusted models were used to estimate reductions in hemoglobin A1c (HbA1c) and body weight. RESULTS: Adjusted analyses using an EHR derived comparison group demonstrated significantly different findings than unadjusted pre to post analyses. The embedded HSS study indicates that appropriate statistical methods, staff with required expertise, and integration with health system data infrastructure are needed to develop timely and rigorous HSS outcomes that effectively improve patient care. CONCLUSIONS: Embedded HSS has the potential to inform value-based care models and contribute to evidence-based medicine approaches that improve patient care. Although developing system wide integrated data structures and staff with the appropriate skills requires substantial effort, the outcome is more reliable evaluations that lead to higher quality and higher value care. IMPLICATIONS: Health care delivery organizations can improve patient care by dedicating resources to embed HSS into its routine operations.


Assuntos
Atenção à Saúde , Programas Governamentais , Registros Eletrônicos de Saúde , Humanos , Assistência Médica , Organizações
2.
Am J Health Promot ; 35(2): 202-213, 2021 02.
Artigo em Inglês | MEDLINE | ID: mdl-32945175

RESUMO

PURPOSE: Previous DPP translations in African American women have been suboptimal. This trial evaluated a community-based participatory research developed faith-based diabetes prevention program (DPP) to improve weight loss in African American women. DESIGN: This cluster randomized trial allocated churches to faith-based (FDPP) or standard (SDPP) DPP interventions. Setting. African American churches. Subjects. Eleven churches with 221 African American women (aged 48.8 ± 11.2 years, BMI = 36.7 ± 8.4) received the FDPP (n = 6) or SDPP (n = 5) intervention. INTERVENTION: FDPP incorporated 5 faith-based components, including pastor involvement, into the standard DPP curriculum. The SDPP used the standard DPP curriculum. Lay health leaders facilitated interventions at church sites. MEASURES: Weight and biometrics were collected by blinded staff at baseline, 4- and 10-months. ANALYSIS: A multilevel hierarchical regression model compared the FDPP and SDPP groups on outcomes. RESULTS: FDPP and SDPP churches significantly lost weight at 10-months (overall -2.6%, p < .01). Women in FDPP churches who attended at least 15 sessions lost an additional 6.1 pounds at 4-months compared to SDPP corresponding to a 5.8% reduction at 10-months (p < .05). Both groups had significant improvements in health behaviors and biometrics. CONCLUSIONS: Faith-based and standard DPP interventions led by lay health leaders successfully improved weight, health behaviors, and chronic disease risk. However, the faith-based DPP when fully implemented met the CDC's recommendation for weight loss for diabetes prevention in African American women.


Assuntos
Diabetes Mellitus Tipo 2 , Perda de Peso , Adulto , Afro-Americanos , Pesquisa Participativa Baseada na Comunidade , Feminino , Comportamentos Relacionados com a Saúde , Promoção da Saúde , Humanos , Pessoa de Meia-Idade
3.
J Eval Clin Pract ; 27(5): 1056-1065, 2021 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33051956

RESUMO

RATIONALE, AIMS, AND OBJECTIVES: The health care delivery model in the United States does not work; it perpetuates unequal access to care, favours treatment over prevention, and contributes to persistent health disparities and lack of insurance. The vast majority of those who suffer from preventable diseases and health disparities, and who are at greatest risk of not having insurance, are low-income minorities (Native Americans, Hispanics, and African-Americans) who live in high risk and vulnerable communities. The historical lack of support in the United States for Universal Health Care (UHC) and Primary Health Care (PHC)-with their emphasis on health care for all, population health, and social determinants of health-requires community health scientists to develop innovative local solutions for addressing unmet community health needs. METHODS: We developed a model community health science approach for improving health in fragile communities, by combining community-oriented primary care (COPC), community-based participatory research (CBPR), asset-based community development, and service learning principles. During the past two decades, our team has collaborated with community residents, local leaders, and many different types of organizations, to address the health needs of vulnerable patients. The approach defines health as a social outcome, resulting from a combination of clinical science, collective responsibility, and informed social action. RESULTS: From 2000 to 2020, we established a federally funded research programme for testing interventions to improve health outcomes in vulnerable communities, by working in partnership with community organizations and other stakeholders. The partnership goals were reducing chronic disease risk and multimorbidity, by stimulating lifestyle changes, increasing healthy behaviours and health knowledge, improving care seeking and patient self-management, and addressing the social determinants of health and population health. Our programmes have also provided structured community health science training in high-risk communities for hundreds of doctors in training. CONCLUSION: Our community health science approach demonstrates that the factors contributing to health can only be addressed by working directly with and in affected communities to co-develop health care solutions across the broad range of causal factors. As the United States begins to consider expanding health care options consistent with PHC and UHC principles, our community health science experience provides useful lessons in how to engage communities to address the deficits of the current system. Perhaps the greatest assets US health care systems have for better addressing population health and the social determinants of health are the important health-related initiatives already underway in most local communities. Building partnerships based on local resources and ongoing social determinants of health initiatives is the key for medicine to meaningfully engage communities for improving health outcomes and reducing health disparities. This has been the greatest lesson we have learned the past two decades, has provided the foundation for our community health science approach, and accounts for whatever success we have achieved.

4.
Healthc (Amst) ; 8(4): 100476, 2020 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-33007650

RESUMO

BACKGROUND: The Embedded Healthcare Research Conference aimed to promote and enhance research-operations partnerships in diverse health care settings. Within this conference, the Priorities and Methods Workgroup set out to define a vision of embedded research that leverages diverse methods to address clearly articulated research questions of importance to health systems. METHODS: The Workgroup session involved a combination of small and large group discussions around three broadly focused topics: the integration of embedded research within the existing quality improvement (QI) ecosystem; the identification, prioritization and formulation of embedded research questions; the creation of an embedded research "tool kit." RESULTS: Workgroup participants envisioned a future for embedded research that is characterized by authentic engagement between researchers and health system leaders; seamless integration between research, QI and clinical operations; clear and explicit articulation of research questions; an appropriate balance between rigor and relevance in applied methodology; alignment between study design, available resources and the importance of the knowledge to be gained; efficient processes; and bi-directional communication. Important barriers to achieving this vision include limited access to executive leaders, silos that discourage integration of research and QI, generally low tolerance for disruption in high-risk clinical settings, limited access to data, and limited availability of researchers with requisite skills and training. CONCLUSIONS: Embedded research holds potential to enhance the relevance, value and use of research, while also creating generalizable knowledge. Key recommendations include building authentic relationships, discouraging silos, encouraging innovation and experimentation, and expanding opportunities for funding research in delivery systems.


Assuntos
Prioridades em Saúde/tendências , Sistema de Aprendizagem em Saúde/métodos , Pesquisa/instrumentação , Educação/métodos , Prioridades em Saúde/normas , Humanos , Sistema de Aprendizagem em Saúde/tendências , Melhoria de Qualidade , Pesquisa/tendências
5.
Nutr Metab Cardiovasc Dis ; 30(10): 1785-1794, 2020 09 24.
Artigo em Inglês | MEDLINE | ID: mdl-32605881

RESUMO

BACKGROUND AND AIMS: Metabolic syndrome (MetS) increases the risk of cardiovascular disease and type 2 diabetes. Despite a higher prevalence of MetS in African American (AA) women, little is known about the effectiveness of lifestyle interventions in improving metabolic markers in this high-risk group. This study investigated the effectiveness of a community-based lifestyle intervention delivered by lay health coaches in reducing MetS among AA women. METHODS AND RESULTS: A cluster-randomized diabetes prevention program (DPP) was implemented in 11 churches utilizing a community-based participatory research (CBPR) approach to develop and deliver the interventions. A total of 221 adults, AA women who were overweight or obese, and did not have diabetes were included in this study. The prevalence of MetS was 42.08% before receiving the DPP intervention and 31.22% after the intervention that represented a 10.86% absolute reduction and a 25.81% relative reduction from baseline. The adjusted odds ratio (OR) of being free from MetS at post-intervention in contrast to baseline was 2.14 (p = 0.02). Factors that increased the odds of being free from MetS were younger age, reduction in intake of total calories, total fat, saturated and trans-fat, and dietary sodium. CONCLUSION: A faith adapted lifestyle intervention held in church settings and delivered by minimally trained lay health coaches reduced the prevalence of MetS in AA women who were overweight or obese. Findings from this study can be used to translate evidence into public health programs at the community level for the prevention of type 2 diabetes and cardiovascular disease. CLINICAL TRIAL REGISTRATION NUMBER: NCT04082702 (www.clinicaltrials.gov).


Assuntos
Afro-Americanos , Serviços de Saúde Comunitária , Diabetes Mellitus Tipo 2/prevenção & controle , Organizações Religiosas , Estilo de Vida Saudável , Síndrome Metabólica/prevenção & controle , Obesidade/terapia , Comportamento de Redução do Risco , Adulto , Cristianismo , Diabetes Mellitus Tipo 2/diagnóstico , Diabetes Mellitus Tipo 2/etnologia , Feminino , Humanos , Síndrome Metabólica/diagnóstico , Síndrome Metabólica/etnologia , Pessoa de Meia-Idade , Obesidade/diagnóstico , Obesidade/etnologia , Prevalência , Fatores de Risco , Fatores Sexuais , Texas/epidemiologia , Resultado do Tratamento
6.
Contemp Clin Trials Commun ; 17: 100540, 2020 Mar.
Artigo em Inglês | MEDLINE | ID: mdl-32090186

RESUMO

Background: Chronic kidney disease (CKD) is commonly asymptomatic until its late stages, reduces life quality and length, is costly to manage, and is disproportionately prevalent in low-income, African American (AA) communities. Traditional health system strategies that engage only patients with symptomatic CKD limit opportunities to prevent progression to end stage kidney disease (ESKD) with the need for expensive kidney replacement therapy and to reduce risk for their major mortality cause, cardiovascular disease (CVD). Published studies show that giving fruits and vegetables (F&V) to AA with early-stage CKD along with preparation instructions slowed CKD progression. This effective, evidenced-based, and potentially scalable dietary intervention might be a component of a community-based strategy to prevent CKD progression. Design: This study supported by NIH grant (R21DK113440) will test the feasibility of an innovative screening strategy conducted at community-based institutions in low-income AA communities and the ability to intervene in individuals identified to have CKD and increased CVD risk with F&V, with or without preparation instructions. Objectives: The study will prospectively compare changes in urine indices predictive of CKD progression and CVD in participants receiving, compared to those not receiving, preparation instructions along with F&V, six months after the intervention. Discussion: Addressing the challenge of increasing progression of early to more advanced stages of CKD with its increased CVD risk requires development of effective strategies to screen, identify, and intervene with individuals found to have CKD with effective, comparatively inexpensive, community-based, and scalable strategies to prevent CKD progression, particularly in low-income, AA communities.

7.
Transl Behav Med ; 10(4): 1064-1069, 2020 10 08.
Artigo em Inglês | MEDLINE | ID: mdl-31167022

RESUMO

Climate-based weight loss interventions, or those that foster a nurturing family environment, address important ecological influences typically ignored by the traditional biomedical treatments. Promoting a climate characterized by positive communication, autonomy support, and parental warmth supports adolescents in making healthy behavioral changes. In addition, encouraging these skills within the family may have additional benefits of improved family functioning and other mental and physical health outcomes. Although several programs have identified essential elements and established the evidence base for the efficacy of these interventions, few have offered resources for the translation of these constructs from theoretical concepts to tangible practice. This paper provides strategies and resources utilized in the Families Improving Together (FIT) for weight loss randomized controlled trial to create a warm, supportive climate characterized by positive communication within the parent-child relationship. Detailed descriptions of how Project FIT emphasized these constructs through facilitator training, intervention curriculum, and process evaluation are provided as a resource for clinical and community interventions. Researchers are encouraged to provide resources to promote translation of evidence-based interventions for programs aiming to utilize a positive climate-based family approach for lifestyle modification.


Assuntos
Relações Pais-Filho , Perda de Peso , Adolescente , Comunicação , Humanos , Estilo de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Traduções
8.
Ethn Dis ; 29(2): 297-308, 2019.
Artigo em Inglês | MEDLINE | ID: mdl-31057315

RESUMO

Introduction: African American (AA) women have disproportionately higher risk of cardiovascular disease than White women, which may be explained by the uniquely higher allostatic load (AL) found in AA women. No studies have tested the effect of lifestyle interventions on AL in AA women. Our objectives were to assess the change in allostatic load following a lifestyle intervention and explore the roles of lifestyle behaviors and socioeconomic factors on allostatic load change. Methods: Participants were non-diabetic (mean age and SD: 48.8±11.2 y) AA women (n=221) enrolled in a church-based, cluster randomized trial testing a standard diabetes prevention program (DPP) and a faith-enhanced DPP with 4-months of follow-up. We assessed the relationships of changes in diet, physical activity, neighborhood disadvantage, individual socioeconomic factors, and other lifestyle variables to changes in AL at 4-months using a multilevel multinomial logistic regression model. Results: Average AL decreased (-.13±.99, P=.02) from baseline to 4-months. After adjusting for other variables, a high school education or less (OR:.1, CI:.02-.49) and alcohol use (OR: .31, CI: .09-.99) contributed to increased AL. Living in a disadvantaged neighborhood was responsible for increased AL, though it was not statistically significant. There were no statistically significant associations between AL and other health behavior changes. Conclusions: Lower education levels may dampen the benefits of lifestyle interventions in reducing AL. Although a significant reduction in AL was found after participation in a lifestyle intervention, more research is needed to determine how lifestyle behaviors and socioeconomic factors influence AL in AA women.


Assuntos
Afro-Americanos/estatística & dados numéricos , Alostase/fisiologia , Doenças Cardiovasculares/prevenção & controle , Comportamentos Relacionados com a Saúde , Estilo de Vida , Adulto , Afro-Americanos/psicologia , Doenças Cardiovasculares/sangue , Exercício Físico , Feminino , Educação em Saúde/métodos , Humanos , Masculino , Pessoa de Meia-Idade , Fatores Socioeconômicos
9.
Acad Med ; 93(9): 1264, 2018 09.
Artigo em Inglês | MEDLINE | ID: mdl-30153160
10.
Health Aff (Millwood) ; 37(4): 543-550, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29608367

RESUMO

Population health strategies that improve access to health care and address social determinants of health may reduce the use of costly emergency services. Here we describe a strategy adopted by Baylor Scott & White Health to reduce rising rates of emergency department use and inpatient hospitalizations in an underserved Dallas community that is home to many people with low socioeconomic status. Baylor Scott & White partnered with the Dallas Park and Recreation Department to create a level-three primary care clinic integrating wellness and prevention programs in a city recreational center. The clinic, known as the Baylor Scott & White Health and Wellness Center, exemplifies the integration of social determinants of health within a population health strategy. Emergency department (ED) and inpatient care use was examined over twelve months after initiation of services at the center. People who used the center's services showed a reduction in ED use of 21.4 percent and a reduction in inpatient care use of 36.7 percent, with an average cost decrease of 34.5 percent and 54.4 percent, respectively. These data support the use of population health strategies to reduce the use of emergency services.


Assuntos
Serviço Hospitalar de Emergência/estatística & dados numéricos , Academias de Ginástica/métodos , Hospitalização/estatística & dados numéricos , Saúde da População , Serviço Hospitalar de Emergência/economia , Feminino , Acesso aos Serviços de Saúde , Hospitalização/economia , Humanos , Masculino , Pessoa de Meia-Idade , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , Estudos Retrospectivos , Fatores Socioeconômicos , Texas
11.
Acad Med ; 93(6): 839-842, 2018 06.
Artigo em Inglês | MEDLINE | ID: mdl-29342009

RESUMO

Improving population health may require health systems to proactively engage patient populations as partners in the implementation of healthy behaviors as a shared value using strategies that incentivize healthy outcomes for the population as a whole. The current reactive health care model, which focuses on restoring the health of individuals after it has been lost, will not achieve the goal of improved population health. To achieve this goal, health systems must proactively engage in partnerships with the populations they serve. Health systems will need the help of community entities and individuals who have the trust of the population being served and are willing to act on behalf of the health system if they are to achieve this effective working partnership. The need for these trusted agents is particularly pertinent for vulnerable and historically underserved segments of the population. In this Invited Commentary, the authors discuss ways by which health systems might identify, engage, and leverage trusted agents to improve the health of the population through value-based care.


Assuntos
Centros Médicos Acadêmicos/métodos , Planejamento em Saúde Comunitária/métodos , Atenção à Saúde/métodos , Saúde da População , Populações Vulneráveis/psicologia , Humanos , Participação dos Interessados , Confiança
12.
Prev Chronic Dis ; 14: E119, 2017 11 22.
Artigo em Inglês | MEDLINE | ID: mdl-29166248

RESUMO

INTRODUCTION: African American women have higher rates of obesity and related chronic disease than other demographic groups. The poorer health of African American women compared with other groups may be explained by allostatic load, or cumulative physiologic stress, due to chronic socioeconomic disadvantage. The objective of this study was to evaluate neighborhood and individual factors contributing to allostatic load in African American women at risk for obesity-related diseases. METHODS: This study evaluated the relationship of allostatic load with neighborhood disadvantage, individual socioeconomic determinants, and synergism between neighborhood and socioeconomic disadvantage, along with health behaviors and other factors as mediators in African American women. Our sample consisted of 220 African American women at risk of obesity-related diseases enrolled in the Better Me Within program (mean [standard deviation] age, 50.1 [11.2] y; mean [standard deviation] body mass index, 36.7 [8.4] kg/m2). Allostatic load score for each participant was calculated by summing the number of biomarkers (of 9 biomarkers) that were determined to be in the high-risk quartile. RESULTS: Poisson regression of neighborhood disadvantage and individual socioeconomic determinants found that neighborhood disadvantage, but not education level or household income, was significantly associated with allostatic load (ß = 0.22, SE, 0.10, P = .04). Tests for mediators showed that household income and alcohol consumption partially mediated the relationship between allostatic load score and neighborhood disadvantage but were not significant. CONCLUSION: More research is necessary to determine the mechanisms by which neighborhoods can exacerbate and attenuate cumulative disadvantage among African American women. Policies and interventions that focus on neighborhood health may improve the outcomes of individual-level health interventions among women who reside in disadvantaged communities.


Assuntos
Afro-Americanos , Obesidade/complicações , Características de Residência , Adulto , Alostase , Biomarcadores , Feminino , Nível de Saúde , Disparidades nos Níveis de Saúde , Humanos , Pessoa de Meia-Idade , Fatores de Risco , Fatores Socioeconômicos
13.
Contemp Clin Trials ; 62: 77-90, 2017 11.
Artigo em Inglês | MEDLINE | ID: mdl-28807739

RESUMO

Reducing obesity positively impacts diabetes and cardiovascular risk; however, evidence-based lifestyle programs, such as the diabetes prevention program (DPP), show reduced effectiveness in African American (AA) women. In addition to an attenuated response to lifestyle programs, AA women also demonstrate high rates of obesity, diabetes, and cardiovascular disease. To address these disparities, enhancements to evidence-based lifestyle programs for AA women need to be developed and evaluated with culturally relevant and rigorous study designs. This study describes a community-based participatory research (CBPR) approach to design a novel faith-enhancement to the DPP for AA women. A long-standing CBPR partnership designed the faith-enhancement from focus group data (N=64 AA adults) integrating five components: a brief pastor led sermon, memory verse, in class or take-home faith activity, promises to remember, and scripture and prayer integrated into participant curriculum and facilitator materials. The faith components were specifically linked to weekly DPP learning objectives to strategically emphasize behavioral skills with religious principles. Using a CBPR approach, the Better Me Within trial was able to enroll 12 churches, screen 333 AA women, and randomize 221 (Mage=48.8±11.2; MBMI=36.7±8.4; 52% technical or high school) after collection of objective eligibility measures. A prospective, randomized, nested by church, design will be used to evaluate the faith-enhanced DPP as compared to a standard DPP on weight, diabetes and cardiovascular risk, over a 16-week intervention and 10-month follow up. This study will provide essential data to guide enhancements to evidence-based lifestyle programs for AA women who are at high risk for chronic disease.


Assuntos
Afro-Americanos , Diabetes Mellitus Tipo 2/etnologia , Diabetes Mellitus Tipo 2/prevenção & controle , Organizações Religiosas/organização & administração , Comportamentos Relacionados com a Saúde/etnologia , Educação em Saúde/organização & administração , Adulto , Glicemia , Pressão Sanguínea , Doenças Cardiovasculares/etnologia , Pesquisa Participativa Baseada na Comunidade , Feminino , Hemoglobina A Glicada , Humanos , Lipídeos/sangue , Pessoa de Meia-Idade , Estudos Prospectivos , Religião , Projetos de Pesquisa , Autoeficácia
14.
Subst Use Misuse ; 37(2): 171-97, 2002 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-11863274

RESUMO

The use of spit tobacco (ST) products is a serious public health problem in the United States. Use of ST is associated with increased risk of oral cancer, gastrointestinal neoplasms, and other deleterious effects. The prevalence of ST use among adolescents is high in many areas, especially in predominantly rural states (e.g., South Dakota, Montana). Community-wide efforts aimed at prevention and cessation of ST use among young people are needed. A total of 4089 clinicians and educators were surveyed in 1998 regarding their personal ST use and several other characteristics associated with ST prevention and cessation counseling. Educators reported significantly higher rates of ST use than did clinicians. The most prevalent barriers to ST counseling among clinicians were perceptions of patient resistance to referral to ST cessation programs and the lack of community services that effectively treat ST use. Lack of training was a major barrier to ST counseling among all educator subgroups. Although knowledge of the health effects of ST was fairly high among all subgroups, more than 10% of dentists and dental hygienists failed to report that ST use causes gum disease. Most clinicians believed that they should demonstrate leadership in efforts aimed at ST control; however, only 64% of dentists believed that repeated counseling attempts were necessary with patients who continued to use ST. Compared with clinicians, educators generally felt less obligated to provide ST counseling. Eighty percent of physicians reported counseling activities, but fewer than half of the dental professionals did. More than 75% of Drug Abuse Resistance Education (DARE) officers reported having delivered ST counseling, whereas only 4% of volunteer leaders did. Fewer than 50% of educators believed that the ST program they taught was effective. Training of various professionals in ST interventions may benefit from emphasizing different issues (reduction of personal ST use, knowledge, commitment, etc.). Our findings have implications for community-based efforts aimed at controlling ST use among young people.


Assuntos
Aconselhamento , Equipe de Assistência ao Paciente , Abandono do Uso de Tabaco/métodos , Tabagismo/reabilitação , Tabaco sem Fumaça/efeitos adversos , Adolescente , Adulto , Feminino , Educação em Saúde , Humanos , Masculino , Pessoa de Meia-Idade , Encaminhamento e Consulta , População Rural , Tabagismo/prevenção & controle
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