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When planning and evaluating community-level initiatives focused on policy and environment change, it is useful to have estimates of the impact on behavioral outcomes of particular strategies (e.g., building a new walking trail to promote physical activity). We have created a measure of estimated strategy-level impact--"population dose"--based on our work in evaluating obesity prevention initiatives that uses elements of the RE-AIM method of combining reach and effectiveness to estimate the impact of a strategy on risk behaviors within a target population. We provide a definition and examples of measuring population dose, discuss measurement options in the face of uncertainty about key parameters, review ways of increasing population dose, and illustrate how the concept of population dose has been used in the Kaiser Permanente Community Health Initiative. (Contains 1 table.)

Objective: To compare knowledge gains and knowledge retention of healthful eating and active living behaviors in elementary school children participating in Educational Theatre Programs (ETP). Methods: The study sample included 47 schools (2,915 third- or fourth-grade students) in 8 Kaiser Permanente regions. Children's knowledge of 4 healthful behaviors was measured using a brief survey before and immediately after performances, followed by a post-delay survey 3 weeks later. Results: Statistically significant increases in knowledge pre/post for individual topics (P less than 0.01). The percentage of children who answered all 4 questions correctly increased from 17% to 63% immediately after ETP performances (P less than 0.01). Knowledge was retained over the short term; the proportion of students who correctly identified recommended healthful eating/active living practices had declined only slightly 3 weeks later. Conclusions and Implications: The ETP significantly improved participating students' knowledge of healthful eating and active living concepts. Theater programs should be considered for inclusion in elementary school health curricula. (Contains 3 tables.)

"Steps to Health King County" ("Steps KC"; Seattle, Washington) was one of 40 community-level initiatives funded in 2003 as part of the "Steps to a HealthierUS" initiative. "Steps KC" goals included reducing the impact of chronic diseases through a comprehensive, coordinated approach and reducing health disparities due to chronic illness. "Steps KC" intervention activities took place on two levels: the overall "Steps KC" collaborative and individual funded programs. Collaborative-level activities included policy and systems change initiatives and efforts to better integrate the funded-program organizations. The funded programs ranged from group health promotion programs to intensive case management. "Steps KC" was successful in creating a large, diverse community collaborative and funding 14 separate programs that reached approximately 8,000 community residents with medium- and high-intensity programs of demonstrated effectiveness. Systems change initiatives within school districts and government agencies led to a greater institutional emphasis on health promotion and on partnership with communities to address health inequities. (Contains 4 tables.)

Context: A 3-year pilot program to expand the role of nurse practitioners (NPs) in the Washington State workers' compensation system was implemented in 2004 (SHB 1691), amid concern about disparities in access to health care for injured workers in rural areas. SHB 1691 authorized NPs to independently perform most functions of an attending physician. Purpose: The aims of this study were to (1) describe the contribution by NPs to Washington's workers' compensation provider workforce, (2) evaluate change in provider availability attributable to SHB 1691, and (3) evaluate the effect of SHB 1691 on timely accident report filing. Methods: Administrative data were used to evaluate this natural experiment, using a pre-post design with primary care physicians (PCPs) as a nonequivalent comparison group. Findings: NPs served injured workers with characteristics similar to those served by PCPs, but 22.0% of NPs were rural, compared with 17.3% of PCPs. Of claimants with NPs as their attending provider, 53.3% were injured in a rural county, compared with 24.7% for those with PCP attending providers. The number of NPs participating in the workers' compensation system rose after SHB 1691 implementation, more so in rural areas. SHB 1691 implementation was associated with a 16 percentage point improvement in timely accident report filing by NPs in both rural and urban areas. Conclusions: Authorizing NPs to function as attending providers for injured workers may improve provider availability (especially in rural areas) and timely accident report filing, which in turn may improve worker outcomes and system costs.

Community health initiatives typically involve time-limited funding from foundation or government grants to support their initial activities. But if there are to be lasting improvements in health outcomes, initiative activities must be sustained over a relatively long period of time. Despite the importance of sustaining work begun under health initiatives, there have been few attempts to track sustainability after the period of funding has ended. This article provides a framework for evaluating the legacy of community health initiatives and illustrates its use with the legacy evaluation from The California Wellness Foundations Health Improvement Initiative (HII). The HII was largely successful in sustaining its core elements of collaborative partnerships, community-level systems changes, direct services, and population health measurement. The authors discuss differences in evaluation design and data collection between the funded-period and legacy evaluations; these differences may justify a distinct methodological approach.

Research indicates that health disparities may be reduced by increasing the number of ethnic minorities working in health occupations. Establishing health career pathway programs for immigrant and ethnic minority students is one way to address this problem. One such program, Cross-Cultural Education in Public Health (CCEPH), was developed, implemented, and evaluated to determine whether participants expressed greater interest in pursuing health care careers after program completion. A sample of 72 immigrant students in two high schools participated in the program, which was based on Bandura's theory of self-efficacy. Data were gathered using pre- and post-program surveys that measured academic self-efficacy and career consideration. Results for academic efficacy were not statistically significant, but interest level in health care careers rose substantially. Although further research needs to be conducted to determine whether such programs increase self-efficacy, programs such as CCEPH can increase the consideration of health careers among immigrant and ethnic minority students. (Contains 4 tables.)

Despite growing support among public health researchers and practitioners for environmental approaches to obesity prevention, there is a lack of empirical evidence from intervention studies showing a favorable impact of either increased healthy food availability on healthy eating or changes in the built environment on physical activity. It is therefore critical that we carefully evaluate initiatives targeting the community environment to expand the evidence base for environmental interventions. We describe the approaches used to measure the extent and impact of environmental change in 3 community-level obesity-prevention initiatives in California. We focus on measuring changes in the community environment and assessing the impact of those changes on residents most directly exposed to the interventions. (Am J Public Health. 2010;100:2129-2136. doi: 10.2105/AJPH. 2010.300002)

Increasing rates of childhood overweight have been linked to the rising energy density of the diet. We sought to provide temporal profiles of dietary energy density (DED) in a nationally representative sample of U.S. children and adolescents [less than or equal to] 19 y old and to describe associations between DED and predictors of overweight. We used a subset of data from the 1994-1996, 1998 Continuing Survey of Food Intake for Individuals (CSFII) and a multivariate regression model to determine independent associations between DED and socioeconomic and demographic variables after controlling for covariates. In this cross-sectional data set, DED was positively associated with total energy intakes and varied with both age and gender. DED increased from birth, peaked at 7-8 y of age, and then declined. Boys consumed more energy-dense diets than girls. Among children [less than or equal to] 4 y old, higher DED was associated in the regression model with lower household incomes and with enrollment in the food stamp program. Among adolescents 12-19 y old, higher DED was associated with being African-American. In contrast, lower DED among children [less than or equal to] 11 y old was associated with being Asian or Hispanic and with total daily consumption of fluid milk. The quality of the diet for young children, as indexed by high DED, may be adversely affected by limited household economic resources. Although food insecurity and WIC enrollment were not associated with DED in this study sample, milk consumption in children [less than or equal to] 4 y old was associated with lower DED. KEY WORDS: * nutrition * dietary energy density * pediatrics * obesity * overweight

Elderly patients whose bile duct is injured during gallbladder surgery may have a higher death rate, according to a study of 1,570,361 patients who were followed for up to 10 years after the operation. Those whose bile duct was injured during the operation were almost three times more likely to die within the next 10 years. Patients who were oldest and had other diseases were most likely to die.