Search

Background Many patients with poorly controlled multiple chronic conditions (MCC) also have unhealthy behaviors, mental health challenges, and unmet social needs. Medical management of MCC may have limited benefit if patients are struggling to address their basic life needs. Health systems and communities increasingly recognize the need to address these issues and are experimenting with and investing in new models for connecting patients with needed services. Yet primary care clinicians, whose regular contact with patients makes them more familiar with patients’ needs, are often not included in these systems. Methods We are starting a clinician-level cluster-randomized controlled trial to evaluate how primary care clinicians can participate in these community and hospital solutions and whether doing so is effective in controlling MCC. Sixty clinicians in the Virginia Ambulatory Care Outcomes Research Network will be matched by age and sex and randomized to usual care (control condition) or enhanced care planning with clinical-community linkage support (intervention). From the electronic health record we will identify all patients with MCC, including cardiovascular disease or risks, diabetes, obesity, or depression. A baseline assessment will be mailed to up to 50 randomly selected patients for each clinician (3000 total). Ten respondents per clinician (600 patients total) with uncontrolled MCC will be randomly selected for study inclusion, with oversampling of minorities. The intervention includes two components. First, we will use an enhanced care planning tool, My Own Health Report (MOHR), to screen patients for health behavior, mental health, and social needs. Patients will be supported by a patient navigator, who will help patients prioritize needs, create care plans, and write a personal narrative to guide the care team. Patients will update care plans every 1 to 2 weeks. Second, we will create community-clinical linkage to help address patients’ needs. The linkage will include community resource registries, personnel to span settings (patient navigators and a community health worker), and care team coordination across team members through MOHR. Discussion This study will help inform efforts by primary care clinicians to help address unhealthy behaviors, mental health needs, and social risks as a strategy to better control MCC. Trial registration ClinicalTrials.gov: NCT03885401. Registered on 19 September 2019.

Objectives. To investigate community health worker (CHW) effects on chronic disease outcomes using electronic health records (EHRs). Methods. We examined EHRs of 32 147 patients at risk for chronic disease during 2012 to 2015. Variables included contact with clinic-based CHWs, vitals, and laboratory tests. We estimated a mixed model for all outcomes. Results. Within-group findings showed statistically significant improvements in chronic disease indicators after exposure to CHWs. In health center 1, HbA1c (glycated hemoglobin) decreased 0.15 millimoles per mole (95% confidence interval [CI] = −0.24, −0.06), body mass index decreased 0.29 kilograms per meter squared (CI = –0.39, −0.20), and total cholesterol decreased 11.9 milligrams per deciliter (CI = −13.5, −10.2). In health center 2, HbA1c decreased 0.43 millimoles per mole (CI = –0.7, −0.17), body mass index decreased by 0.08 kilograms per meter squared (CI = −0.14, −0.02), and triglycerides decreased by 22.50 milligrams per deciliter (CI = −39.0, −6.0). Total cholesterol of 3.62 milligrams per deciliter (CI = −6.6, −0.6) in health center 1 was the only improvement tied to CHW contact. Conclusions. Although patients’ chronic disease indicators consistently improved, between-group models provided no additional evidence of impact. EHRs’ evolution may elucidate CHW contributions moving forward.

The purpose of this study was to determine if the associations between eating competence (EC) and eating behaviors that were found in a USA sample of predominantly Hispanic parents of 4th grade youth could be replicated in a USA sample of predominantly non-Hispanic white parents of 4th graders. Baseline responses from parents (n = 424, 94% white) of youth participating in a year-long educational intervention were collected using an online survey. Validated measures included the Satter Eating Competence Inventory (ecSI 2.0TM), in-home fruit/vegetable (FV) availability, healthful eating behavior modeling, and FV self-efficacy/outcome expectancies (SE/OE). Data were analyzed with general linear modeling and cluster analyses. The findings replicated those from the primarily Hispanic sample. Of the 408 completing all ecSI 2.0TM items, 86% were female, 65% had a 4-year degree or higher, and 53% were EC (ecSI 2.0TM score &ge, 32). Compared with non-EC parents, EC modeled more healthful eating, higher FV SE/OE, and more in-home FV availability. Behaviors clustered into those striving toward more healthful practices (strivers, n = 151) and those achieving them (thrivers, n = 255). Striver ecSI 2.0TM scores were lower than those of thrivers (29.6 &plusmn, 7.8 vs. 33.7 &plusmn, 7.6, p &lt, 0.001). More EC parents demonstrated eating behaviors associated with childhood obesity prevention than non-EC parents, encouraging education that fosters parent EC, especially in tandem with youth nutrition education.

PURPOSE To describe the frequency and patient-reported readiness to change, desire to discuss, and perceived importance of 13 health risk factors in a diverse range of primary care practices. METHODS Patients (n = 1,707) in 9 primary care practices in the My Own Health Report (MOHR) trial reported general, behavioral, and psychosocial risk factors (body mass index [BMI], health status, diet, physical activity, sleep, drug use, stress, anxiety or worry, and depression). We classified responses as “at risk” or “healthy” for each factor, and patients indicated their readiness to change and/or desire to discuss identified risk factors with providers. Patients also selected 1 of the factors they were ready to change as most important. We then calculated frequencies within and across these factors and examined variation by patient characteristics and across practices. RESULTS On average, patients had 5.8 (SD = 2.12; range, 0–13) unhealthy behaviors and mental health risk factors. About 55% of patients had more than 6 risk factors. On average, patients wanted to change 1.2 and discuss 0.7 risks. The most common risks were inadequate fruit/vegetable consumption (84.5%) and overweight/obesity (79.6%). Patients were most ready to change BMI (33.3%) and depression (30.7%), and most wanted to discuss depression (41.9%) and anxiety or worry (35.2%). Overall, patients rated health status as most important. CONCLUSIONS Implementing routine comprehensive health risk assessments in primary care will likely identify a high number of behavioral and psychosocial health risks. By soliciting patient priorities, providers and patients can better manage counseling and behavior change.

PURPOSE Guidelines recommend screening patients for unhealthy behaviors and mental health concerns. Health risk assessments can systematically identify patient needs and trigger care. This study seeks to evaluate whether primary care practices can routinely implement such assessments into routine care. METHODS As part of a cluster-randomized pragmatic trial, 9 diverse primary care practices implemented My Own Health Report (MOHR)—an electronic or paper- based health behavior and mental health assessment and feedback system paired with counseling and goal setting. We observed how practices integrated MOHR into their workflows, what additional practice staff time it required, and what percentage of patients completed a MOHR assessment (Reach). RESULTS Most practices approached (60%) agreed to adopt MOHR. How they implemented MOHR depended on practice resources, informatics capacity, and patient characteristics. Three practices mailed patients invitations to complete MOHR on the Web, 1 called patients and completed MOHR over the telephone, 1 had patients complete MOHR on paper in the office, and 4 had staff help patients complete MOHR on the Web in the office. Overall, 3,591 patients were approached and 1,782 completed MOHR (Reach = 49.6%). Reach varied by implementation strategy with higher reach when MOHR was completed by staff than by patients (71.2% vs 30.2%, P

OBJECTIVES: Characterize parent (P) weight change 2–5 y post participation in Fuel for Fun (FFF) a controlled trial of a school and family intervention focused on culinary and physical activity experiences for 4th grade youth. METHODS: P who had participated with their 4th grader in FFF were recruited via email to enroll in a follow-up (FFF-FU) assessment. FFF-FU survey set included measures from the original study and new items pertinent to P of adolescents. Physical activity was measured with the IPAQ; low income was denoted as using an income-based program or worry about money for food. Height, weight, age in FFF and FFF-FU were self-reported. Perimenopausal age included 47 y within BL and FFF-FU. Youth in FFF cohorts 1 and 4 were controls and cohorts 2 and 3 included the multi-component intervention. P were enrolled in 1 of 4 treatments varying in type and intensity. FFF and FFF-FU data were collected online using the Qualtrics platform. FFF P completed surveys at baseline (BL), post-intervention, and 4 months post-study. FFF-FU data were collected spring 2018, about 2 to 5 years years post-BL. Data were analyzed with repeated measures controlling for BL or FFF-FU sociodemographics, engagement, health behaviors. RESULTS: Of the 418 FFF P, 127 completed FFF-FU surveys (mean age 42.5 6.0 y) with 115 providing weight and height. FFF-FU sample was female (88%), white (84%), active (44% high activity), educated (69% college degree or higher), but had lower BMI and fewer with low income than FFF P. Of FFF-FU providing heights/weights at the 4 assessments, mean (SE) BMIs were 24.2 (0.5), 24.4 (0.5), 24.6 (0.6) and 25.7 (0.6) respectively. Change in BMI was significant after controlling for age, stress, ethnicity, sex, physical activity level, P treatment and engagement, but not when BL to FFU-FU change in age or perimenopausal age were controlled. The significantly greater increase in BMI for P of intervention youth than controls persisted when controlling for sociodemographic and health behavior findings, but not when BL to FFF-FU age change, perimenopausal age or activity level were controlled. CONCLUSIONS: Significant weight gain by P of youth in a nutrition intervention 2 to 5 years post-study was unrelated to stress, ethnicity, activity level, income, but was related to the FFF-FU age change from BL and perimenopausal age. FUNDING SOURCES: NIFA.

Tobacco smoking is still one of the most important risk factor for Respiratory and cardiovascular diseases and an estimated 90% of causes of lung cancer are attributable to Tobacco smocking and equally 90% of peripheral vascular disease in non-diabetic population is attributable to Tobacco smoking, despite the health effect there is disturbing figures of people who take up smoking habit daily and increase level of failed quit smoking attempts.Environment and genetics still plays major role, and various forms of tobacco is used worldwide and its health consequence has been highlighted. Monitoring tobacco use and prevention policies through effective tax laws is paramount to reduction of the tobacco health effects in our environments.Keywords: Tobacco abuse, cigarrete smoking, health effect

Patient-centered health risk assessments (HRAs) that screen for unhealthy behaviors, prioritize concerns, and provide feedback may improve counseling, goal setting, and health. To evaluate the effectiveness of routinely administering a patient-centered HRA, My Own Health Report, for diet, exercise, smoking, alcohol, drug use, stress, depression, anxiety, and sleep, 18 primary care practices were randomized to ask patients to complete My Own Health Report (MOHR) before an office visit (intervention) or continue usual care (control). Intervention practice patients were more likely than control practice patients to be asked about each of eight risks (range of differences 5.3-15.8 %, p

Objectives: Several studies have shown that causes of adult hypertension arise in childhood, and obesity may be a potential cause or at least a mitigating factor in this development. Body mass index is a well studied obesity metric, yet other potential adiposity measures such as percent body fat and waist circumference have been somewhat less considered. The purpose of this study is to determine associations between these alternative serial childhood adiposity measures and adulthood blood pressure. Methods: Measurements from participants in the Fels Longitudinal Study were used to summarize childhood adiposity, represented by childhood measurements of percent body fat and height-adjusted waist circumference. These subjects also provided systolic and diastolic blood pressure as adults. Childhood adiposity levels were categorized as high or low as compared to the respective upper quartile, and associations with adult blood pressure were measured using Poisson regression to estimate the number of expected occurrences of elevated adiposity during childhood. Adult lifestyle covariates and adiposity were accounted for using multiple linear regression. Results: Summary indices of the childhood adiposity measures were significantly associated with both adult blood pressure metrics in men and women, though some of these associations were altered or reduced in the presence of adult lifestyle characteristics and adult adiposity measures. Conclusions: Childhood measures of percent body fat and height-adjusted waist circumference have an effect on adult blood pressure, though the effect can be mitigated by adult lifestyles. Am. J. Hum. Biol., 2010. © 2010 Wiley-Liss, Inc.

Focus group interviews were conducted to explore sociocultural, environmental, and policy-related determinants of physical activity among sedentary American Indian women. Thirty women aged 20 to 50 years (mean = 37.4 +/- 10.6 years) participated. Three sessions were conducted with women aged 20 to 34 years and three with women aged 35 to 50 to evaluate response differences by age. Because no obvious age differences were observed, data were pooled. Barriers to physical activity included inadequate support for household and child care responsibilities and difficulties balancing home-related and societal expectations with physical activity. In addition, women reported little support from their communities and work sites to be physically active. Environmental barriers included lack of safe outdoor areas and accessible walking trails. Weather and stray dogs were also commonly mentioned. Sociocultural barriers included giving family obligations priority above all other things, being expected to eat large portions of high-fat foods, and failing to follow a traditionally active lifestyle. Enablers of physical activity included support from family and coworkers and participation in traditional community events. Suggested intervention approaches included accessible and affordable programs and facilities, community emphasis on physical activity, and programs that incorporated the needs of larger women and of families. Participants emphasized a preference for programs that were compatible with the role expectations of their families and communities, and they expressed the desire for acceptance and encouragement to be physically active from the family, the community, the worksite, and their tribal leaders.

Cooking with Kids (CWK), an experiential school-based food education program, has demonstrated modest influence on fruit and vegetable preference, food and cooking attitudes (AT), and self-efficacy (SE) among fourth-grade, mostly low-income Hispanic students in a quasiexperimental study with an inconsistent baseline. Effect was notably strong for boys and those without previous cooking experience. The aim of this project was to assess the effect of CWK with a mostly non-Hispanic white sample that assured no previous CWK exposure.The randomized, controlled assessment of CWK effect on fourth graders was conducted with 257 students in 12 classes in four public schools. CWK included a 1-hour introductory lesson, three 2-hour cooking classes, and three 1-hour fruit and vegetable tasting sessions led by trained food educators during the school day for one semester. Fruit preference, vegetable preference, and cooking AT and SE were assessed with a tested 35-item measure, shown to have test-retest reliability. Univariate analyses considered gender and previous cooking experience.Intervention efficacy was confirmed in this mostly white sample (75%; 79% with previous cooking experience; 54% girls). Increases in vegetable preference, AT, and SE were all significantly greater in CWK students with ηp (2) of 0.03, 0.02, and 0.06, respectively. CWK most strongly improved AT and SE for boys without previous cooking experience.CWK significantly improved fourth-grade students' vegetable preferences, AT, and SE toward food and cooking, which are factors important to healthful eating and obesity prevention. Noncookers, especially boys, benefitted from this intervention.

Background There is a pressing need for greater attention to patient-centered health behavior and psychosocial issues in primary care, and for practical tools, study designs and results of clinical and policy relevance. Our goal is to design a scientifically rigorous and valid pragmatic trial to test whether primary care practices can systematically implement the collection of patient-reported information and provide patients needed advice, goal setting, and counseling in response. Methods This manuscript reports on the iterative design of the My Own Health Report (MOHR) study, a cluster randomized delayed intervention trial. Nine pairs of diverse primary care practices will be randomized to early or delayed intervention four months later. The intervention consists of fielding the MOHR assessment – addresses 10 domains of health behaviors and psychosocial issues – and subsequent provision of needed counseling and support for patients presenting for wellness or chronic care. As a pragmatic participatory trial, stakeholder groups including practice partners and patients have been engaged throughout the study design to account for local resources and characteristics. Participatory tasks include identifying MOHR assessment content, refining the study design, providing input on outcomes measures, and designing the implementation workflow. Study outcomes include the intervention reach (percent of patients offered and completing the MOHR assessment), effectiveness (patients reporting being asked about topics, setting change goals, and receiving assistance in early versus delayed intervention practices), contextual factors influencing outcomes, and intervention costs. Discussion The MOHR study shows how a participatory design can be used to promote the consistent collection and use of patient-reported health behavior and psychosocial assessments in a broad range of primary care settings. While pragmatic in nature, the study design will allow valid comparisons to answer the posed research question, and findings will be broadly generalizable to a range of primary care settings. Per the pragmatic explanatory continuum indicator summary (PRECIS) framework, the study design is substantially more pragmatic than other published trials. The methods and findings should be of interest to researchers, practitioners, and policy makers attempting to make healthcare more patient-centered and relevant. Trial registration Clinicaltrials.gov: NCT01825746

Objective: To examine reliability of validity-tested instruments measuring fruit and vegetable (FV) preference and self-efficacy (SE) for and attitude (AT) toward cooking. Methods: In Santa Fe, New Mexico, following cognitive interviews with 123 fourth- and fifth-graders, surveys were administered twice, less than 2 weeks apart, to students in 16 classrooms without intervening nutrition education. Results were assessed using Pearson correlation coefficient, Cronbach a, marginal homogeneity, Wilcoxon, and paired t tests. Results: Individual test-retest scores were significantly (P < .001) correlated (n ¼ 344; 72.9% Hispanic); r ¼ 0.80 (SE), 0.82 (AT), and 0.88 (FV). Cronbach a was $ 0.74 for all survey administrations. Classroom test-retest scores were significantly correlated (SE r ¼ 0.66, AT r ¼ 0.88, and FV r ¼ 0.92). Self-efficacy and AT toward cooking were higher in girls (P < .001). Conclusions and Implications: Validity-tested 8-item SE, 6-item AT, and 16-item FV surveys showed internal consistency and test-retest reliability and are suitable for impact assessment of cooking-based education interventions, specifically Cooking with Kids.

Pathways to Health is a cancer prevention and health promotion curriculum for fifth- and seventh-grade Navajo and Pueblo students living in New Mexico.A diet and nutrition questionnaire was administered to 1007 fifth- and seventh-grade students before beginning the Pathways to Health intervention. Sections of the questionnaire included listing favorite foods, frequency of intake of selected foods (e.g., "How often do you eat vegetables?"), targeted food practices (e.g., "When you eat chicken, do you eat the skin?"), and applied dietary fat and fiber knowledge questions. Descriptive analyses were generated by grade, gender, and tribe.Students' favorite foods were pizza, hamburgers, and tacos. Only 35.7% of students reported consuming the U.S. Dietary Guidelines recommendation of two or more daily servings of fruit, with only 19.3% reporting more than once-a-day intake of vegetables. The mean score (percent correct responses) to questions identifying common food sources of dietary fat and fiber, and other cancer-related nutrition knowledge questions, was 45.2% and 57.9% for fifth- and seventh-grade students, respectively.These and related data support the need for nutrition education interventions in this population that target essential cancer prevention skills and motivational information required to make positive dietary choices.