Assessing social values for California's efforts to reduce the overuse of unnecessary medical care.

BACKGROUND: A partnership of large health-care purchasers created a workgroup to reduce the overuse of harmful and wasteful medical care in California. OBJECTIVE: Employ a civic engagement process to identify the social values important to the public in considering different strategies to reduce overuse. INTERVENTION: Use of deliberation techniques for 3 case examples that explore possible strategies: physician oversight, physician compensation, increased patient cost-sharing or taking no definitive action. RESULTS: Five themes were identified, including strong support for physicians' leadership role to reduce overuse; nuanced enthusiasm for increasing patient cost-sharing to discourage excessive demand; and marked disapproval of physician compensation as a motivator. CONCLUSION: Most but not all of the perspectives voiced by participants are congruent with efforts to reduce overuse that is being initiated or discussed at the state, provider and health plan level. As health-care policymakers and leaders consider more targeted approaches to reducing overuse, these findings will inform decision-making.

Implementing a Quality Improvement Collaborative to Improve Hypertension Control and Advance Million Hearts Among Low-Income Californians, 2014-2015.

From January through December 2015, the California Department of Health Care Services, which administers Medi-Cal, the nation's largest Medicaid program, conducted a quality improvement collaborative (QIC) with 9 Medi-Cal managed care plans (MCPs) aimed at improving hypertension control consistent with the Million Hearts initiative. The QIC included quarterly webinars and links to local, state, and national resources that consisted of materials and consultations with subject matter experts. Participating MCPs demonstrated an average increase of 5.0 percentage points in their rates of controlled hypertension. Collaboratives can achieve substantial quality improvement in Medicaid managed care plans.

Restructuring a State Nutrition Education and Obesity Prevention Program: Implications of a Local Health Department Model for SNAP-Ed.

CONTEXT AND OBJECTIVE: The US Department of Agriculture Supplemental Nutrition Assistance Program-Education (SNAP-Ed) funds state programs to improve nutrition and physical activity in low-income populations through its Nutrition Education and Obesity Prevention grants. States vary in how they manage and structure these programs. California substantially restructured its program in 2012 to universally position local health departments (LHDs) as the programmatic lead in all jurisdictions. This study sought to determine whether California's reorganization aligned with desirable attributes of decentralized public management. DESIGN, SETTING, AND PARTICIPANTS: This study conducted 40 in person, semistructured interviews with 57 local, state, and federal SNAP-Ed stakeholders between October 2014 and March 2015. Local respondents represented 15 counties in all 7 of California's SNAP-Ed regions. We identified 3 common themes that outlined advantages or disadvantages of local public management, and we further defined subthemes within: (1) coordination and communication (within local jurisdictions, across regions, between local and state), (2) efficiency (administrative, fiscal, program), and (3) quality (innovation, skills). We conducted qualitative content analysis to evaluate how respondents characterized the California experience for each theme, identifying positive and negative experiences. RESULTS: California's LHD model offers some distinct advantages, but the model does not exhibit all the advantages of decentralized public management. Strategic planning, partnerships, subcontracting, and fiscal oversight are closer to communities than previously. However, administrative burden remains high and LHDs are limited in their ability to customize programs on the basis of community needs because of state and federal constraints. CONCLUSIONS: California's use of a universal LHD model for SNAP-Ed is novel. Recent federal SNAP-Ed changes present an opportunity for other states to consider this structure. Employing small-scale approaches initially (eg, pilot efforts) may facilitate effective transitions. For an LHD model to be effective, LHDs must be adept at managing administrative complexity and capable of succeeding within stringent federal/state requirements.

Health Promotion Interventions for Low-Income Californians Through Medi-Cal Managed Care Plans, 2012.

INTRODUCTION: Prevention is the most cost-effective approach to promote population health, yet little is known about the delivery of health promotion interventions in the nation's largest Medicaid program, Medi-Cal. The purpose of this study was to inventory health promotion interventions delivered through Medi-Cal Managed Care Plans; identify attributes of the interventions that plans judged to have the greatest impact on their members; and determine the extent to which the plans refer members to community assistance programs and sponsor health-promoting community activities. METHODS: The lead health educator from each managed care plan was asked to complete a 190-item online survey in January 2013; 20 of 21 managed care plans responded. Survey data on the health promotion interventions with the greatest impact were grouped according to intervention attributes and measures of effectiveness; quantitative data were analyzed using descriptive statistics. RESULTS: Health promotion interventions judged to have the greatest impact on Medi-Cal members were delivered in various ways; educational materials, one-on-one education, and group classes were delivered most frequently. Behavior change, knowledge gain, and improved disease management were cited most often as measures of effectiveness. Across all interventions, median educational hours were limited (2.4 h), and median Medi-Cal member participation was low (265 members per intervention). Most interventions with greatest impact (120 of 137 [88%]) focused on tertiary prevention. There were mixed results in referring members to community assistance programs and investing in community activities. CONCLUSION: Managed care plans have many opportunities to more effectively deliver health promotion interventions. Establishing measurable, evidence-based, consensus standards for such programs could facilitate improved delivery of these services.

Cost-Effectiveness Analysis of a Community-Based Telewellness Weight Loss Program.

Introduction: The purpose of this study was to perform a cost-effectiveness analysis of the Koa Family Program, a community-based telewellness weight reduction intervention for overweight and obese women aged 21-45 years with low income. The Koa Family Program resulted in an approximately 8-pound weight loss as demonstrated in an RCT published previously. Methods: Estimates for the cost-effectiveness were derived from the prospective 25-week RCT including 70 women (25 kg/m2≤BMI<40 kg/m2). The analysis was from a program-funder perspective. Base case costs, as well as low and high scenario costs, were estimated from the services provided to intervention participants. The incremental costs were compared with the incremental effectiveness, with weight loss being the outcome of interest. Costs were in 2021 U.S. dollars. Cost-effectiveness was assessed using the incremental cost-effectiveness ratio and the incremental net benefit. The statistical uncertainty was characterized using an incremental net benefit by willingness-to-pay plot and a cost-effectiveness acceptability curve. Results: The base case average cost per participant was $564.39. The low and high scenario average costs per participant were $407.34 and $726.22, respectively. Over the 25-week study timeframe, participants lost an average 7.7 pounds, yielding a base case incremental cost-effectiveness ratio of approximately $73 per extra pound lost. The probability that the Koa Family Program is cost-effective is 90%, assuming a willingness-to-pay of $115 for a 1-pound reduction, and is 95%, assuming a willingness-to-pay of $140. Conclusions: The Koa Family Program provides good value with cost-effectiveness in line with other weight-loss interventions. This is a striking finding given that the Koa Family Program serves a more vulnerable population than is typically engaged in weight loss research studies.

A Quality Strategy to Advance the Triple Aim in California's Medicaid Program.

The California Department of Health Care Services (DHCS) administers the nation's largest Medicaid program. In 2012, DHCS developed a Quality Strategy modeled after the National Quality Strategy to guide the Department's activities aimed at advancing the Triple Aim. The Triple Aim seeks to improve the patient experience of care and the health of populations as well as reduce the per capita cost of health care. An academic team was contracted to assist DHCS in developing the strategy, which also was informed by extensive stakeholder input, an advisory committee, and a comprehensive inventory of DHCS quality improvement (QI) activities. From 2012 to 2018, the strategy included 129 unique QI activities. Most activities were intended to deliver more effective, efficient, affordable care or to advance disease prevention. This qualitative assessment of the DHCS Quality Strategy provides insights that may inform other Medicaid programs or large health systems as they develop quality strategies.

A cross-sectional prevalence study of ethnically targeted and general audience outdoor obesity-related advertising.

CONTEXT: Commercial marketing is a critical but understudied element of the sociocultural environment influencing Americans' food and beverage preferences and purchases. This marketing also likely influences the utilization of goods and services related to physical activity and sedentary behavior. A growing literature documents the targeting of racial/ethnic and income groups in commercial advertisements in magazines, on billboards, and on television that may contribute to sociodemographic disparities in obesity and chronic disease risk and protective behaviors. This article examines whether African Americans, Latinos, and people living in low-income neighborhoods are disproportionately exposed to advertisements for high-calorie, low nutrient-dense foods and beverages and for sedentary entertainment and transportation and are relatively underexposed to advertising for nutritious foods and beverages and goods and services promoting physical activities. METHODS: Outdoor advertising density and content were compared in zip code areas selected to offer contrasts by area income and ethnicity in four cities: Los Angeles, Austin, New York City, and Philadelphia. FINDINGS: Large variations were observed in the amount, type, and value of advertising in the selected zip code areas. Living in an upper-income neighborhood, regardless of its residents' predominant ethnicity, is generally protective against exposure to most types of obesity-promoting outdoor advertising (food, fast food, sugary beverages, sedentary entertainment, and transportation). The density of advertising varied by zip code area race/ethnicity, with African American zip code areas having the highest advertising densities, Latino zip code areas having slightly lower densities, and white zip code areas having the lowest densities. CONCLUSIONS: The potential health and economic implications of differential exposure to obesity-related advertising are substantial. Although substantive legal questions remain about the government's ability to regulate advertising, the success of limiting tobacco advertising offers lessons for reducing the marketing contribution to the obesigenicity of urban environments.

Multiple health benefits of urban tree canopy: The mounting evidence for a green prescription.

The purpose of this study was to enhance the understanding of the health-promoting potential of trees in an urbanized region of the United States. This was done using high-resolution LiDAR and imagery data to quantify tree cover within 250m of the residence of 7910 adult participants in the California Health Interview Survey, then testing for main and mediating associations between tree cover and multiple health measures. The results indicated that more neighborhood tree cover, independent from green space access, was related to better overall health, primarily mediated by lower overweight/obesity and better social cohesion, and to a lesser extent by less type 2 diabetes, high blood pressure, and asthma. These findings suggest an important role for trees and nature in improving holistic population health in urban areas.

Psychosocial predictors of healthful dietary behavior in adolescents.

OBJECTIVE: To identify predictors of healthful dietary practices in adolescents using the Theory of Planned Behavior and determine how gender and ethnicity influence the relationship among the theoretical constructs. DESIGN: Initial and 1-month follow-up questionnaires, designed to measure the constructs of the Theory of Planned Behavior and select demographic items, were administered to the participants in the spring of 1997 to gather data for this descriptive research. SETTINGS/PARTICIPANTS: A sample of 780 adolescents, aged 14 to 19 years, was recruited from randomly selected science classes at 4 public high schools in San Bernardino, California. Seven hundred and fifty participants (96%) completed the initial questionnaire and 672 (86%) completed the follow-up questionnaire. ANALYSIS: A 5-step hierarchical multiple regression procedure, general linear model analysis, and Tukey's honestly significant difference post hoc test were used to analyze the data. RESULTS: Intention to eat a healthful diet was a predictor of healthful dietary behavior. Intention was influenced most by attitude and then by perceived behavioral control and subjective norm. Those with positive attitudes toward healthful eating believed that they would like the taste of healthful foods, feel good about themselves, tolerate giving up foods that they like to eat, and lose weight or maintain a healthful weight. Mother, siblings, and friends were identified as important predictors of subjective norm. Knowledge about how to eat a healthful diet, availability of healthful foods, motivation, and access to enough money were salient facilitating factors related to perceived behavioral control. Interesting contrasts among gender and ethnic groups also were noted. CONCLUSIONS AND IMPLICATIONS: The findings indicate that multiple attitudinal, normative, and control factors influence healthful dietary behavior in adolescents. The synergistic use of these factors in the development and implementation of nutrition education interventions may assist in the promotion of healthful eating among teens from culturally diverse communities.

Effect of fresh fruit availability at worksites on the fruit and vegetable consumption of low-wage employees.

OBJECTIVE: To examine the impact of fresh fruit availability at worksites on the fruit and vegetable consumption and related psychosocial determinants of low-wage employees. DESIGN: A prospective, randomized block experimental design. SETTING: Seven apparel manufacturing and 2 food processing worksites. PARTICIPANTS: A convenience sample of 391 low-wage employees in 6 intervention worksites and 137 low-wage employees in 3 control worksites in Los Angeles, CA. INTERVENTION: Fresh fruit deliveries with enough for 1 serving per employee, 3 days a week for 12 consecutive weeks. The control worksites did not receive the fruit deliveries. MAIN OUTCOME MEASURES: Participants' fruit and vegetable consumption, fruit and vegetable purchasing habits, self-efficacy, job satisfaction, and overall health were measured at baseline, weeks 4 and 8, and following the 12-week intervention. ANALYSIS: Descriptive statistics and growth curve analysis using hierarchical linear modeling were employed to analyze the data. RESULTS: Participants in the intervention worksites showed a significant increase in fruit, vegetable, and total fruit and vegetable consumption, purchasing of fruit, family purchasing of vegetables, and self-efficacy toward eating 2 servings of fruit each day compared to the control worksites. CONCLUSIONS AND IMPLICATIONS: Improving access to fruit during the workday can improve fruit and vegetable consumption, purchasing habits, and self-efficacy of low-income employees.

The Power Play! Campaign's School Idea & Resource Kits improve determinants of fruit and vegetable intake and physical activity among fourth- and fifth-grade children.

OBJECTIVE: Examine the effect of the California Children's Power Play! Campaign's School Idea & Resource Kits for fourth/fifth grades on the psychosocial determinants of fruit and vegetable (FV) intake and physical activity (PA). METHODS: Randomized, controlled trial (n = 31 low-resource public schools; 1,154 children). Ten grade-specific, 50-minute nutrition and PA lessons over an 8-week period. Pre/post surveys measuring knowledge, outcome expectations, and self-efficacy (SE) were analyzed using analysis of covariance, controlling for baseline values; chi-square comparing positive/negative changes, adjusted for cluster design effects. RESULTS: Intervention children made significant gains for FV knowledge (4 items, P < .05 to P < .001); positive outcome expectations (fifth grade only, P < .001); asking/shopping and eating SE (P = .04 and P < .001); PA knowledge (2 items, P < .01 to P < .001); outcome expectations (P < .05); and support seeking SE (P = .04); but not SE to overcome barriers. CONCLUSIONS AND IMPLICATIONS: The Power Play! Campaign's School Idea & Resource Kits improved the determinants of FV intake and PA.

Using an opinion poll to build an obesity-prevention social marketing campaign for low-income Asian and Hispanic immigrants: report of findings.

OBJECTIVE: To gain opinions from low-income, limited-English-speaking Hispanic and Asian immigrants for formative research in a social marketing campaign. DESIGN: Nineteen questions on obesity prevention-related topics were embedded into a larger random digit-dial survey investigating the effects of language and cultural barriers on health care access. Participants were selected by ethnic encoding from consumer databases. SETTING: California's northern, southern, and Central Valley regions. PARTICIPANTS: Nine hundred and five adult Hispanic, Chinese, Vietnamese, Hmong, and Korean Californians from households < 130% of the Federal Poverty Level interviewed in 2005. VARIABLES MEASURED: Media usage, food stamp participation, health insurance, health problems, access and availability of fruits and vegetables (FVs) and physical activity, beliefs about overweight, and related regulation and policy change. ANALYSIS: Descriptive statistics and percentages for all questions. RESULTS: Latinos reported receiving most information from television; Hmong from radio. Hispanics, Koreans, and Vietnamese thought diabetes was the greatest health issue in California. Among Hmong, 83% thought FVs were too expensive, and 49% of Vietnamese thought good quality, affordable fresh FVs were too hard to find. CONCLUSIONS AND IMPLICATIONS: Identifying characteristics and opinions that distinguish these ethnic immigrant populations better enables the Network for a Healthy California to develop culturally relevant social marketing campaigns and materials.

Using a Toolbox of tailored educational lessons to improve fruit, vegetable, and physical activity behaviors among African American women in California.

OBJECTIVE: Evaluate the effectiveness of the Fruit, Vegetable, and Physical Activity Toolbox for Community Educators (Toolbox), an intervention originally designed for Spanish- and English-speaking audiences, in changing knowledge, attitudes, and behavior among low-income African American women. DESIGN: Quasi-experimental design with treatment and control groups. SETTING: Four community-based organizations and direct health service provider sites. PARTICIPANTS: African American women ages 18-54 (156 treatment, 171 control), 75% of whom were low income. INTERVENTION: Six 1-hour Toolbox classes. MAIN OUTCOME MEASURES: Knowledge, attitudes, self-efficacy, empowerment, and behavior change related to fruits and vegetables and physical activity. ANALYSIS: Dependent t tests pre- to posttest and chi-square test between control and treatment groups. RESULTS: Women in the treatment group reported significant changes in 9 measures of attitude, compared to 1 measure in the control group, as well as 12 measures of confidence and 5 measures of empowerment for which the control group showed no changes. Compared to those in the control group, women in the treatment group were also more likely to make behavioral changes to meet recommendations for fruit and vegetable consumption and physical activity. CONCLUSIONS AND IMPLICATIONS: Toolbox lessons were effective in increasing participants' knowledge, attitudes, self-efficacy, empowerment, and reported fruit and vegetable- and physical activity-related behaviors.

Acculturation and gender: influence on healthy dietary outcomes for Latino adolescents in California.

OBJECTIVE: Examine acculturation and gender on intention to eat a healthful diet among Latino adolescents using the Theory of Planned Behavior. DESIGN: Secondary analysis of data set and condensed version of the Short Acculturation Scale for Hispanics (SASH). SETTING: Data collected from 34 randomly selected high schools in San Bernardino, CA. PARTICIPANTS: 265 Latino high school adolescents. MAIN OUTCOME MEASURES: Effects of acculturation and gender on variables of the Theory of Planned Behavior on intention to eat a healthful diet. ANALYSIS: Multiple regression analysis examined acculturation/gender differences, and modifications on the prediction of intention. General linear modeling determined differences across gender and acculturation groups. RESULTS: Females had stronger intention, more positive attitude, and greater subjective normative influence. Females indicated feeling healthy and looking good and males indicated good athletic performance as contributors to eating healthfully. Mother was influential for both genders, and stronger for females. Siblings were influential for less acculturated males, and friends were influential for highly acculturated females. Less acculturated adolescents had stronger intention to eat healthfully, more tolerance to give up liked food items, and more support and encouragement. CONCLUSIONS AND IMPLICATIONS: Professionals need to take into account gender and acculturation differences when making dietary recommendations for Latino adolescents.