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Purpose Understanding the climate of safety is a core initiative of the US fire service in its quest to reduce injuries, fatalities, and toxic exposures linked to occupational disease. The purpose of this study was to develop a fire service safety climate scale to support this goal. Method Survey development followed an exploratory sequential mixed methods design combining qualitative methods (interviews and focus groups with 123 firefighters to generate items), and quantitative methods (exploratory and confirmatory factor analyses; multi-level models) to examine the survey’s psychometric properties in a geographically-stratified random sample of 130 fire departments including 615 stations and 8575 firefighters. Results Based on the EFA results, a 14-item multi-level measure of fire service safety climate containing two factors—management commitment (fire department-level) and supervisor support (fire station-level)—was developed. Results of multi-level CFAs indicated acceptable fit of the measurement model, supporting construct validity. Multi-level path analyses showed that fire service safety climate scores were significantly related to safety-related outcomes such as injury rates and safety compliance along with well-being focused outcomes such as job satisfaction, burnout, and employee engagement, supporting criterion-related validity. Discussion A reliable and valid fire service safety climate scale was developed. The scale’s dimensions of management commitment within fire department and supervisor support within stations are embedded in a larger instrument, the Fire service Organizational Culture of Safety survey (FOCUS). This simple tool allows fire departments to assess shared perceptions of safety policies and practices and the impact of such perceptions on safety and organizational outcomes.

We assessed restaurant workers' knowledge and practices regarding food allergy management and adverse events, which result in 90,000 emergency department visits annually in the United States. We surveyed all eligible restaurants within a defined catchment in Philadelphia and 80.3% (n = 187) participated. No restaurant employee was able to name all seven “best practices” to reduce the risk of food allergy adverse events in restaurants. The majority of participants could name only zero or one preventive measure. Few participants knew to respond to anaphylaxis by administering epinephrine and calling 9-1-1. Public health professionals should work with the restaurant industry, and with food service workers, to evaluate and revise food allergy-relevant policies and trainings. This is critical to protect the 15 million American consumers, and far more globally, who suffer from food allergies.

Highlights • Campaigns can recruit African Americans to glaucoma screenings and studies. • Marketing with community partners successfully reached the target audience. • Radio commercials and postcards were most cost-effective in recruiting patients., Our objective was to determine which messaging approaches from a marketing campaign were most effective in recruiting African American individuals to a glaucoma screening and research study. We conducted a multimedia marketing campaign in Philadelphia from 01/31/2018 to 06/30/2018. Messaging approaches included radio advertisements and interviews (conducted in partnership with a local radio station with a large African American listener base), print materials, event tables, and online postings. Participants received free glaucoma screenings and the opportunity to enroll in our glaucoma genetics study. These screenings allowed individuals with glaucoma to receive a full examination and treatment plan with a glaucoma specialist, as well as to contribute to future efforts to identify genetic variants underlying this disease. We compared inquiry, enrollment, and cost yield for each messaging approach. Our campaign resulted in 154 unique inquiries, with 98 patients receiving glaucoma screenings (64%) and 60 patients enrolling in our study (39%). Commercials on WURD radio yielded the highest number of inquiries (62%) and enrollments (62%), but at relatively high cost ($814/enrolled patient). The most inexpensive approach that yielded more than five enrollments was postcards ($429/enrolled patient). Our campaign suggests that high-frequency commercials and postcards distributed at targeted healthcare locations are particularly effective and affordable options for connecting with the African American community. Our findings can help to inform recruitment efforts for other understudied diseases in minority populations.

To respond to the high prevalence of obesity and its associated health consequences, recent food research and policy have focused on neighborhood food environments, especially the links between health and retail mix, proximity of food outlets, and types of foods available. In addition, the social environment exerts important influences on food-related behaviors, through mechanisms like role-modeling, social support, and social norms. This study examined the social dynamics of residents' health-related food-shopping behaviors in 2010-11 in urban Philadelphia, where we conducted 25 semi-structured resident interviews-the foundation for this paper-in addition to 514 structured interviews and a food environment audit. In interviews, participants demonstrated adaptability and resourcefulness in their food shopping; they chose to shop at stores that met a range of social needs. Those needs ranged from practical financial considerations, to fundamental issues of safety, to mundane concerns about convenience, and juggling multiple work and family responsibilities. The majority of participants were highly motivated to adapt their shopping patterns to accommodate personal financial constraints. In addition, they selectively shopped at stores frequented by people who shared their race/ethnicity, income and education, and they sought stores where they had positive interactions with personnel and proprietors. In deciding where to shop in this urban context, participants adapted their routines to avoid unsafe places and the threat of violence. Participants also discussed the importance of convenient stores that allowed for easy parking, accommodation of physical disabilities or special needs, and integration of food shopping into other daily activities like meeting children at school. Food research and policies should explicitly attend to the social dynamics that influence food-shopping behavior. In our social relationships, interactions, and responsibilities, there are countless opportunities to influence-and also to improve-health.

OBJECTIVES: This study explored chronic disease self-management over the monthly benefit cycle among primary food shoppers from households receiving Supplemental Nutrition Assistance Program (SNAP) benefits in Philadelphia, Pennsylvania. METHODS: In-depth interviews, participant observation and surveys were conducted with the primary food shopper of SNAP households (n = 18). Interviews and surveys were conducted in a clinical setting, at participants’ homes, and in food procurement settings including grocery stores, food pantries and soup kitchens. RESULTS: All households had at least one member with a chronic disease or condition; 5 with a diet-related chronic condition, 5 managing the chronic condition of a family member, and 13 with overweight or obesity. Households reported that the dietary demands of managing chronic illnesses were expensive and mentally taxing. Food and financial shortfalls at the end of the benefit cycle, as well as reliance on charitable food assistance programs, often had negative impacts on chronic disease self-management. CONCLUSIONS: Drawing from nearly 50 hours of in-depth qualitative interviews with SNAP participants, this study highlights the dual cognitive burden of poverty and chronic disease and elucidates the particular challenges of food procurement and maintenance of diet quality throughout the benefit month faced by SNAP households with diet-related chronic diseases. Interventions targeted at reducing the cost of medically appropriate, healthy foods may help to improve chronic disease self-management within SNAP populations. FUNDING SOURCES: This work was supported by the University of Pennsylvania Leonard Davis Institute of Health Economics, the University of Pennsylvania Graduate and Professional Student Assembly Provost Award for Interdisciplinary Innovation, the NIH NIDDK Pediatric Endocrine Fellowship Training in Diabetes Research, and the Investment for the Future Initiative in Community Practices, University of Pennsylvania School of Nursing. The sources of financial support had no role in the design, analysis, or writing of this abstract.

Background Food environments may promote or undermine healthy behaviors, but questions remain regarding how individuals interact with their local food environments. Purpose This study incorporated an urban food environment audit as well as an examination of residents’ food shopping behaviors within that context. Methods In 2010, the research team audited the variety and healthfulness of foods available in 373 Philadelphia stores, using the validated Nutrition Environment Measures Survey in Stores (NEMS-S); higher scores indicate more diverse and healthful food inventories. The team also surveyed urban residents (n=514) regarding their food shopping. Descriptive and multivariate analyses (conducted in 2012) assessed variation in retail food environments and in shoppers’ store choices. Results Corner and convenience stores were common (78.6% of food retail outlets) and had the lowest mean NEMS-S scores of any store type. Most participants (94.5%) did their primary food shopping at higher-scoring chain supermarkets, and the majority of participants did not shop at the supermarket closest to home. Supermarket offerings varied, with significantly fewer healthful foods at supermarkets closest to the homes of disadvantaged residents. In multivariate analyses, participants were significantly more likely to shop at supermarkets closest to home if those supermarkets had higher NEMS-S scores. Conclusions These data suggest that, when possible, shoppers chose supermarkets that offered more variety and more healthful foods. Findings from this study also reinforce concern regarding unhealthy immediate food environments for disadvantaged residents, who disproportionately relied on nearby stores with more limited food items. Interventions to improve nutrition and health should address not only food store proximity but also diversity of healthful foods available.

Background Many cardiovascular epidemiologic studies rely on diagnosis codes in health care claims databases. Despite important changes in the care and diagnosis of acute myocardial infarction (AMI), the validity of hospital discharge diagnosis codes for AMI in the US Medicare system has not been recently examined. Our objective was to examine the accuracy of International Classification of Diseases—ninth revision—Clinical Modifications (ICD-9-CM) discharge diagnosis codes and diagnosis-related groups (DRG) codes for AMI in a Medicare claims database. Methods We sampled hospitalization episodes from Medicare beneficiaries in Pennsylvania during 1999, 2000, or both. We used Medicare data to identify patients with hospitalizations containing indicators of AMI (ICD-9-CM diagnosis codes 410.X0 and 410.X1 or DRG codes 121, 122, and 123). Hospital records for these episodes were reviewed by trained abstractors using World Health Organization criteria for diagnosing AMI. We then calculated the positive predictive value of Medicare claims-based definitions of AMI. Results Of 2200 hospitalization episodes with Medicare diagnosis codes suggestive of AMI, 2022 hospital records (91.9%) were obtained. The positive predictive value for a primary Medicare claims-based definition was 94.1% (95% CI, 93.0%–95.2%). Positive predictive values for alternative claims-based definitions ranged slightly, with the definition including DRG codes and length-of-stay restrictions yielding the highest positive predictive value, 95.4% (95% CI, 94.3%–96.4%). Subjects with a history of myocardial infarction had a significantly lower positive predictive value than subjects without a history of myocardial infarction (88.1% vs 94.6%, P Conclusions In this study, we observed high positive predictive values for a Medicare claims-based diagnosis of AMI and a diagnosis based on structured hospital record review.

Study objective Patient handoffs are known as high-risk events for medical error but little is known about the professional, structural, and interpersonal factors that can affect the patient transition from emergency medical services (EMS) care to the emergency department (ED). We study EMS providers' perspectives to generate hypotheses to inform and improve this handoff. Methods We conducted focus groups with EMS providers recruited at 3 national and regional conferences from January to March 2011 until theme saturation was reached; 7 focus groups were conducted with 48 EMS providers. Deidentified transcripts and notes were entered into QSR NVivo, coded, and analyzed to identify themes. Results EMS providers identified themselves as advocates for their patients during the challenging EMS-to-ED handoffs. Providers identified normative challenges they encounter in their communications with hospital staff, and features of EMS and hospital protocols that either facilitate or undermine effective handoffs from the out-of-hospital environment to the ED. They identified 4 key potential ways to improve the structure and process of the handoff: (1) communicate directly with the ED provider responsible for the patient's care; (2) increase interdisciplinary feedback, transparency, and shared understanding of scope of practice between out-of-hospital and hospital-based providers; (3) standardize some (but not all) aspects of the handoff; and (4) harness technology to close gaps in information exchange. Conclusion These exploratory findings suggest that the effect of increasing EMS interactions with emergency physicians, standardizing handoff processes, and fostering interprofessional learning represent opportunities for future study and may serve as potential solutions for the high-risk EMS-ED patient transition.

Methods/Session Descriptions. Data Sources: Literature published up to 2011 was reviewed using PubMed, MEDLINE, CINAHL, and EMBASE using the search terms ‘‘surrogate,’’ ‘‘proxy,’’ ‘‘end-of-life,’’ ‘‘life support withdrawal/withholding,’’ and ‘‘decision-making’’. Study Selection. Selection criteria included: (a) studies or integrative reports of the empirical and theoretical research relevant to EOL surrogate decision-making; (b) articles aiming to produce a model of how SDMs make decisions for decisionally-incapacitated patients with relevance to the context of EOL; and (c) authors depicting diagrammatically their model of surrogate decisionmaking specifying key concepts and theoretical relationships. Articles focusing upon decisionmaking for decisionally-incapacitated children were excluded. Data Extraction. A total of eight theoretical models meeting the selection criteria were identified. Data Synthesis. Five key insights were that: 1) diagrammatic maps of surrogate decision-making lacked consistency with model descriptions; 2) most models focused on description of concepts with a lesser focus on relational linkages and propositions; 3) ethical concepts and relationships have been insufficiently depicted in conceptual maps; 4) little emphasis was placed on how theoretical frameworks might guide intervention development; and 5) minimal attempts have been made to situate surrogate decision-making within a grander conceptual framework of decision-making. Conclusion. Several theories of surrogate decision-making at adult EOL have been proposed but further theory development is needed for design of decision support interventions.

Objective: Design and evaluate a pilot intervention to address barriers to healthy food access and activity in urban Philadelphia neighborhoods. Description: Informed by a mixed-methods assessment of residents' shopping and physical activity patterns and barriers and facilitators to healthy food access and activity, and observational assessments of local food environments, we engaged community members in designing a program emphasizing ‘‘block-based’’ environmental changes to prevent or reduce obesity. Evaluation: The Our Healthy Block program was carefully monitored and pre-post surveys were used for outcome evaluation. Conclusions and Implications: Strategies and findings will be presented. Funding: USDA Grant #2010-85215-20659

Background Foreclosure rates have risen rapidly since 2005, reaching historically high levels. The purpose of this study was to examine the health implications of the current housing crisis. Methods We conducted a cross-sectional online consumer panel survey including residents of California, Arizona, Nevada, and Florida (n = 798) to determine the feasibility of contacting distressed homeowners via the Internet and to assess mental and physical health among respondents across the spectrum from those having no housing strain to those in loan default or home foreclosure. Results Homeowners in default or foreclosure exhibited poorer mental health and more physical symptoms than renters, homeowners with moderate strain, and homeowners with no strainofollowing a gradient that was consistent across multiple health indicators. Conclusions Internet panel sampling was an efficient method of contacting distressed homeowners. Record-high foreclosure rates may have broad implications for nursing and public health. Homeowners in default or foreclosure represent an identifiable high-risk group that may benefit from coordinated, affordable health and social services.