Knowledge and Beliefs About Pedestrian Safety in an Urban Community: Implications for Promoting Safe Walking.

As more people walk for transport and exercise, it is possible to avoid a concomitant increase in the number of pedestrian injuries. Understanding how the public views pedestrian safety can help inform the development of prevention strategies that support national efforts to promote walking and walkable communities. As part of the formative research for a community pedestrian safety health promotion campaign, we administered an online questionnaire to employees and students at a large urban medical campus, along with residents in the neighboring communities, to determine their knowledge, attitudes, and behavior regarding pedestrian safety; awareness of relevant traffic safety laws; and effective strategies that could improve pedestrian safety. Pearson Chi square Test of Independence was used to investigate differences between individuals who mainly traveled as drivers versus those who mainly traveled as pedestrians. Statistical significance was established at p < .05. A total of 3808 adults completed the online survey. More drivers than pedestrians reported that pedestrian safety was an important problem (73 and 64%, respectively; p < .001). A large proportion of respondents incorrectly reported the existing state laws addressing right of way, fines, and enforcement, with significant differences between drivers and pedestrians (p < .001). Significantly more pedestrians than drivers supported changing traffic signals to increase crossing time (p = .001), while more drivers than pedestrians supported creating structures to prevent midblock crossing (p = .003). Effective interventions to improve pedestrian safety need to tailor messages for both drivers and pedestrians, increase awareness of the laws, and implement comprehensive strategies.

A qualitative study of facilitators and barriers to implementing worksite policies that support physical activity.

BACKGROUND: Physical inactivity is associated with several chronic diseases that are costly to society, employers, and individuals. Workplaces are a common location for physical activity (PA) initiatives because of the amount of time individuals who are employed full time spend at work. This research examined a statewide worksite wellness program, the Healthiest Maryland Businesses (HMB) program, to fill an important gap regarding the facilitators for and barriers to implementing workplace policies that support PA. METHODS: Individual telephone interviews were conducted in December 2015 with six HMB Coordinators and their supervisor, and from August through October 2016 with a purposeful sample of 15 businesses of various sizes from across Maryland, to learn about the role of leadership, and successes and challenges of implementing PA programs and policies. The sample of businesses was intentionally selected to capture perspectives from a range of businesses. Interviews were recorded and professionally transcribed. Descriptive coding was used to identify dominant themes that addressed the study aims and research questions. RESULTS: PA was not described as a priority for several large and small businesses. To garner more support for PA, interviewees emphasized associating PA initiatives with measures the businesses care about, such as health care costs from claims data. Small businesses also described having a need for PA programming yet reported having significant resource constraints. There was a strong interest in developing guidance for implementing PA break policies, which was mentioned as a critical support for workplace PA promotion. More commitment and investment of resources from leadership, and an engaged wellness committee with company representation at all levels and roles, were identified as vital for impactful programs. CONCLUSIONS: Most businesses are implementing PA programs with limited policy supports, which was mentioned as a barrier. Successful implementation of workplace wellness programs broadly, and PA initiatives specifically, are achievable through leadership buy-in, employee input, and policy supports, along with highlighting the economic benefits for businesses.

Building safety into active living initiatives.

OBJECTIVE: Efforts to promote environmental designs that facilitate opportunities for physical activity should consider the fact that injuries are the leading cause of death for Americans ages 1 to 44, with transportation-related injuries the most common cause. Drawing on the latest research and best practices in the field of injury prevention, the purpose of this article is to provide those working to promote physical activity with evidence-based recommendations on building in safety while designing active environments. METHOD: A systematic review of the peer-reviewed and grey literature published from 1995 to 2012 was conducted to identify injury prevention strategies applicable to objectives in the Active Design Guidelines (ADG), which present design strategies for active living. Injury prevention strategies were rated according to the strength of the research evidence. RESULTS: We identified 18 urban design strategies and 9 building design strategies that promote safety. Evidence was strong or emerging for 14/18 urban design strategies and 7/9 building design strategies. CONCLUSION: ADG strategies are often wholly compatible with well-accepted injury prevention principles. By partnering with architects and planners, injury prevention and public health professionals can help ensure that new and renovated spaces maximize both active living and safety.

Working inside the firehouse: developing a participant-driven intervention to enhance health-promoting behaviors.

Cardiovascular disease (CVD) is the most common cause of on-duty death among U.S. firefighters among whom volunteers comprise 71% of the fire service. We sought to understand CVD risk among volunteer firefighters and to develop a CVD intervention based on their input. To accomplish these aims, we conducted a series of focus groups with volunteer firefighters and firefighters who serve with volunteers in Maryland. We conducted two additional focus groups with fire service leaders. Ninety-eight people participated in 15 focus groups. Participants discussed health and wellness, stress and the demanding nature of the volunteer fire service, and the challenges associated with healthy eating. They talked about food in the firehouse and the lack of quick, healthy, satisfying, and affordable food. Several suggestions for interventions to improve the food environment and firefighters' ability to choose and prepare healthy meals and snacks emerged. An intervention reflecting the participants' recommendations resulted. The way volunteer firefighters understand health and wellness and the specific factors that influence their food intake are valuable insights for addressing CVD risks in this population. To our knowledge, this is the first study that systematically brings firefighters into the process of developing an intervention to reduce CVD risk among this high-risk population.

Delirium after coronary artery bypass graft surgery and late mortality.

OBJECTIVE: Delirium is common after cardiac surgery, although under-recognized, and its long-term consequences are likely underestimated. The primary goal of this study was to determine whether patients with delirium after coronary artery bypass graft (CABG) surgery have higher long-term out-of-hospital mortality when compared with CABG patients without delirium. METHODS: We studied 5,034 consecutive patients undergoing CABG surgery at a single institution from 1997 to 2007. Presence or absence of neurologic complications, including delirium, was assessed prospectively. Survival analysis was performed to determine the role of delirium in the hazard of death, including a propensity score to adjust for potential confounders. These analyses were repeated to determine the association between postoperative stroke and long-term mortality. RESULTS: Individuals with delirium had an increased hazard of death (adjusted hazard ratio [HR], 1.65; 95% confidence interval [CI], 1.38-1.97) up to 10 years postoperatively, after adjustment for perioperative and vascular risk factors. Patients with postoperative stroke had a HR of 2.34 (95% CI, 1.87-2.92). The effect of delirium on subsequent mortality was the strongest among those without a prior stroke (HR 1.83 vs HR 1.11 [with a prior stroke] [p-interaction = 0.02]) or who were younger (HR 2.42 [<65 years old] vs HR 1.49 [>/=65 years old] [p-interaction = 0.04]). INTERPRETATION: Delirium after cardiac surgery is a strong independent predictor of mortality up to 10 years postoperatively, especially in younger individuals and in those without prior stroke. Future studies are needed to determine the impact of delirium prevention and/or treatment in long-term patient mortality.

Applying the Haddon Matrix to evaluate sexual assault interventions on college campuses.

Objective: A Haddon Matrix analysis was used to systematically review literature evaluating college campus sexual assault prevention programs to identify research gaps and intervention opportunities. Methods: Articles included were published from January 1, 2001 to December 31, 2017; indexed in PubMed, PsycInfo, or Scopus; involving English-speaking undergraduate students in the US; with experimental or quasi-experimental design. Results: All 31 eligible studies evaluated educational programing; all relied on self-report measures; and three-quarters had follow-up periods ≤ 6 months. Significant positive effects were reported by 6 of 10 studies that measured bystander behavior, 6 of 10 that educated potential victims and assessed victimization, and one of four that educated potential perpetrators and measured perpetration. Conclusion: The Haddon Matrix analysis identified the need for interventions that address perpetrators and the post-assault period, as well as studies of the impact of enforcing existing policies and new environmental and situational approaches to sexual assault prevention.

Cognition 6 years after surgical or medical therapy for coronary artery disease.

OBJECTIVE: The choice of coronary artery bypass grafting (CABG) as an intervention for coronary artery disease has been clouded by concerns about postoperative cognitive decline. Long-term cognitive decline after CABG has been reported, but without appropriate control subjects, it is not known whether this decline is specific to CABG or related to other factors such as cerebrovascular disease. METHODS: This prospective, observational study of patients with diagnosed coronary artery disease included 152 CABG and 92 nonsurgical cardiac comparison patients from one institution. The main outcome measure was within-patient change in cognitive performance for eight cognitive domains from baseline to 12- and 72-month follow-up. RESULTS: Mild late cognitive decline was observed for both study groups, but despite greater than 80% power to detect a 0.2 standard deviation difference, there were no statistically significant differences between the surgical and nonsurgical patients in the degree of change from 12 to 72 months for any cognitive domain. There was also no difference between groups in the degree of change from baseline to 72 months or in the number of patients with a Mini-Mental State Examination score in the clinically impaired range at 72 months. INTERPRETATION: Late cognitive decline does occur in patients who have undergone CABG surgery, but the degree of this decline does not differ from that observed in patients of similar age with coronary artery disease who have not undergone CABG. Therefore, late cognitive decline after CABG is not specific to the use of cardiopulmonary bypass.

Developing role models for health in the fire service: a pilot case study.

OBJECTIVES: The objectives of this case study were to develop role models for health in the fire service through knowledge and behaviour change, to improve the role models' own health, and to facilitate behaviour change in other firefighters through their example. DESIGN: Volunteers interested in improving their own health and serving as role models to others in the fire service were identified at a statewide Maryland fire service leadership meeting. SETTING: Participants worked with the Johns Hopkins Weight Management Center to learn how to improve their own health and shared that knowledge with others in their fire departments. PARTICIPANTS: Three Maryland fire service leaders were recruited at a leadership meeting with the goal of improving their own health and becoming role models. One participant dropped out shortly after beginning, while two male participants, aged 57 and 61, completed the study. MAIN OUTCOME MEASURES: Quantitative measures were collected at baseline and 12 months, and included weight, blood pressure and fasting glucose and cholesterol. Semi-structured interviews were conducted approximately 14 months postintervention to determine the participants' perceptions of their own health and impact on others in the fire service. RESULTS: Each participant had biweekly to monthly visits over a one-year period to learn the knowledge and skills that would assist him with improving dietary behaviours, increasing fitness and achieving a healthy weight. Case study participants experienced reductions in body weight (-13% and -11% of total body weight), glucose and blood pressure. Qualitative one-on-one interviews conducted postintervention with the participants revealed that they embraced their status as role models and felt their success inspired other firefighters. Their experiences suggest that role models can play an important role in helping firefighters increase self-efficacy, self-regulation and social support in the workplace environment. CONCLUSIONS: These findings provide promising evidence for the use of role models to improve health, especially in the workplace.

"One of my fears is that physically or mentally, the time will come where I'll be unable to drive anymore. and I'm not looking forward to that": a mixed methods feasibility study to assess older driver's risk impairment.

Sixty-seven older adults were assessed using multiple validated tools. The current study aimed to identify high-, medium-, and low-risk impairment among older drivers and to explore high-risk drivers' reactions to being told their results. Of 67 adults screened from a convenience sample of older drivers, nine high-risk participants, four completed in-depth follow-up qualitative interviews. The quantitative assessment algorithm identified 13% as high risk, 30% as medium risk, and 57% as low risk, and only Trails B distinguished the medium- and high-risk impairment groups. Although the assessment tests did not predict future crash involvement over a 7-month period, four participants in the medium- and high-risk impairment categories had been involved in a crash during the 5 years prior to the study compared with none of those who screened low risk. Only three participants (1 high risk) voluntarily surrendered their driver's licenses after the assessment, and one participant in the in-depth interviews reported that the assessment influenced the decision to stop driving. There may be some benefit in using driving record history and assessment results to determine driving risk impairment level. However, more research is needed to determine the best combination of tools to predict risk level. How to best communicate risk levels remains to be determined, although results from the older drivers in this study underscore the need for great sensitivity when identifying areas of concern about driving ability.

Translating community-based participatory research principles into practice.

BACKGROUND: Although academics are trained in research methods, few receive formal training in strategies for implementing equitable community engaged research. Academics and their community partners can benefit from such direction and assistance as they establish and maintain community-based participatory research (CBPR) partnerships. Research partners from the University of Pittsburgh, the Johns Hopkins Center for Injury Research and Policy, and the House of Ruth Maryland, one of the nation's leading domestic violence centers serving Baltimore and the surrounding areas, joined together to design, implement, and evaluate a series of activities to increase local CPBR capacity. OBJECTIVES: This article provides an overview of process and findings from two CBPR workshops jointly held for academic and community members and explores specific suggestions from the workshop participants about how to put the CBPR principles into practice to promote community engaged research to address intimate partner violence (IPV). METHODS: Twenty-four academic and community partners with experience addressing IPV participated in the two workshops. Facilitators led discussions based on the core CPBR principles. Participants were asked to interpret those principles, identify actions that could help to put the principles into practice, and discuss challenges related to CBPR approaches for IPV research. Observational notes and transcripts of the discussions and workshop evaluations are summarized. RESULTS: The CBPR principles were interpreted and revised through consensus into common language that reflected the group discussion of the core CBPR principles. Workshop participants provided a range of actions for putting the principles into practice and identified the need for sensitivity in relation to IPV research. A majority of participants felt that the workshop generated novel ideas about how they could use CPBR in their own work. CONCLUSIONS: Translating CBPR principles into common, action-oriented language is a useful first step when building a new academic-community research partnership.

Association between hypotension, low ejection fraction and cognitive performance in cardiac patients.

BACKGROUND AND PURPOSE: Impaired cardiac function can adversely affect the brain via decreased perfusion. The purpose of this study was to determine if cardiac ejection fraction (EF) is associated with cognitive performance, and whether this is modified by low blood pressure. METHODS: Neuropsychological testing evaluating multiple cognitive domains, measurement of mean arterial pressure (MAP), and measurement of EF were performed in 234 individuals with coronary artery disease. The association between level of EF and performance within each cognitive domain was explored, as was the interaction between low MAP and EF. RESULTS: Adjusted global cognitive performance, as well as performance in visuoconstruction and motor speed, was significantly directly associated with cardiac EF. This relationship was not entirely linear, with a steeper association between EF and cognition at lower levels of EF than at higher levels. Patients with low EF and low MAP at the time of testing had worse cognitive performance than either of these alone, particularly for the global and motor speed cognitive scores. CONCLUSIONS: Low EF may be associated with worse cognitive performance, particularly among individuals with low MAP and for cognitive domains typically associated with vascular cognitive impairment. Further care should be paid to hypotension in the setting of heart failure, as this may exacerbate cerebral hypoperfusion.

Do management strategies for coronary artery disease influence 6-year cognitive outcomes?

BACKGROUND: Previous uncontrolled studies have suggested that there is late cognitive decline after coronary artery bypass grafting that may be attributable to use of the cardiopulmonary bypass pump. METHODS: In this prospective, nonrandomized, longitudinal study, we compared cognitive outcomes after on-pump coronary artery bypass surgery (n = 152) with off-pump bypass surgery patients (n = 75); nonsurgical cardiac comparison subjects (n = 99); and 69 heart-healthy comparison (HHC) subjects. The primary outcome measure was change from baseline to 72 months in the following cognitive domains: verbal memory, visual memory, visuoconstruction, language, motor speed, psychomotor speed, attention, executive function, and a composite global score. RESULTS: There were no consistent differences in 72-month cognitive outcomes among the three groups with coronary artery disease (CAD). The CAD groups had lower baseline performance, and a greater degree of decline compared with HHC. The degree of change was small, with none of the groups having more than 0.5 SD decline. None of the groups was substantially worse at 72 months compared with baseline. CONCLUSIONS: Compared with subjects with no vascular disease risk factors, the CAD patients had lower baseline cognitive performance and greater degrees of decline over 72 months, suggesting that in these patients, vascular disease may have an impact on cognitive performance. We found no significant differences in the long-term cognitive outcomes among patients with various CAD therapies, indicating that management strategy for CAD is not an important determinant of long-term cognitive outcomes.

Subjective memory symptoms in surgical and nonsurgical coronary artery patients: 6-year follow-up.

BACKGROUND: Self-reported cognitive and memory complaints after coronary artery bypass graft (CABG) operations are common. Several studies have attempted to quantify the incidence of such complaints and to examine the relationship between subjective and objective cognitive functioning, but the etiology and longitudinal course of these self-reports remain unclear. METHODS: Measures of subjective memory complaints were compared in two groups: 220 CABG patients and 92 nonsurgical cardiac patients at 3 months, and 1, 3, and 6 years. At 6 years, additional measures were used to quantify memory self-assessment. The frequency of subjective complaints at each time point was determined, and associations with objective cognitive performance as well as depression were examined. RESULTS: At early (3-month or 1-year) follow-up, subjective memory complaints were reported more often by the CABG than the nonsurgical group (45.5% vs 17.0%, p < 0.0001). By 6 years, the frequency of complaints was similar (52%) in both groups. Subjective memory ratings were significantly correlated with performance on several memory tests at 6 years. This relationship was not confounded by depression. CONCLUSIONS: Subjective memory complaints are more frequent early in follow-up in patients undergoing CABG than in controls, but are similar by 6 years. The increase in subjective complaints over time may be related to progression of underlying cerebrovascular disease. Unlike previous studies, we found that subjective memory assessments were correlated with objective performance on several memory tests. Although subjective memory complaints are more common in patients with depression, they cannot be explained by depression alone.

Neurocognitive outcomes 3 years after coronary artery bypass graft surgery: a controlled study.

BACKGROUND: Cardiopulmonary bypass has been implicated in the late cognitive decline that has been reported after coronary artery bypass graft (CABG) surgery. Because most studies did not include a control group, a causal link of such decline with the use of cardiopulmonary bypass has not been established. METHODS: We compared changes in cognitive performance from baseline to 3 years in patients undergoing on-pump CABG (n = 152) with those of three control groups: patients with off-pump surgery (n = 75); with diagnosed coronary artery disease but no surgery (n = 99); and without coronary artery disease risk factors (n = 69). Neuropsychological performance was assessed by standardized tests of attention, language, verbal and visual memory, visuospatial, executive function, and psychomotor and motor speed. RESULTS: Relative to their baseline performance, no group had significantly lower performance at 36 months for any of the cognitive domains. From 12 to 36 months, there were no statistically significant differences in the degree of change between the on- and off-pump surgery groups. There was a trend toward mild decline in some cognitive domains, but overall differences among groups in degree of change over time were not statistically significant. CONCLUSIONS: We found a mild but nonsignificant trend toward late postoperative cognitive decline for all study groups with coronary artery disease, but no significant differences in the degree of late postoperative cognitive decline after on-pump compared with off-pump surgery. These findings suggest that previously reported late decline after bypass surgery is not specific to use of cardiopulmonary bypass.