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PurposeWe aimed to advance the internal and external validity of research by sharing our empirical experience and recommendations for systematically reporting contextual factors.MethodsFourteen teams conducting research on primary care practice transformation retrospectively considered contextual factors important to interpreting their findings (internal validity) and transporting or reinventing their findings in other settings/situations (external validity). Each team provided a table or list of important contextual factors and interpretive text included as appendices to the articles in this supplement. Team members identified the most important contextual factors for their studies. We grouped the findings thematically and developed recommendations for reporting context.ResultsThe most important contextual factors sorted into 5 domains: (1) the practice setting, (2) the larger organization, (3) the external environment, (4) implementation pathway, and (5) the motivation for implementation. To understand context, investigators recommend (1) engaging diverse perspectives and data sources, (2) considering multiple levels, (3) evaluating history and evolution over time, (4) looking at formal and informal systems and culture, and (5) assessing the (often nonlinear) interactions between contextual factors and both the process and outcome of studies. We include a template with tabular and interpretive elements to help study teams engage research participants in reporting relevant context.ConclusionsThese findings demonstrate the feasibility and potential utility of identifying and reporting contextual factors. Involving diverse stakeholders in assessing context at multiple stages of the research process, examining their association with outcomes, and consistently reporting critical contextual factors are important challenges for a field interested in improving the internal and external validity and impact of health care research.

Background: This study gauged the cost-effectiveness of a community-based health coaching intervention aimed at improving diet and physical activity among women in culturally diverse communities. Methods: The Coalition for a Healthier Community for Utah Women and Girls recruited women from 5 cultural and ethnic groups and randomized them to receive quarterly versus monthly health coaching. Coaching was performed by trained community health workers from the targeted communities. Cost-effectiveness ratios were estimated to gauge the cost-effectiveness of the intervention. Results: Estimated quality-adjusted life years gained from both increased physical activity and improved diet were positive. Cost-effectiveness ratios varied by intervention arm, but all ratios fell within the favorable range described in the literature. Conclusions: This culturally adapted health coaching intervention was deemed to be cost-effective. Our findings suggest that to achieve the highest level of cost-effectiveness, programs should focus on enrolling at-risk women who do not meet recommended physical activity standards and/or dietary guidelines. [ABSTRACT FROM AUTHOR]

Before a 1996 US regulation requiring fortification of enriched cereal-grain products with folic acid, 3 economic evaluations projected net economic benefits or cost savings of folic acid fortification resulting from the prevention of pregnancies affected by a neural tube defect. Because the observed decline in neural tube defect rates is greater than was forecast before fortification, the economic gains are correspondingly larger. Applying both cost-benefit and cost-effectiveness analytic techniques, we estimated that folic acid fortification is associated with annual economic benefit of $312 million to $425 million. The cost savings (net reduction in direct costs) were estimated to be in the range of $88 million to $145 million per year. (Am J Public Health. 2005; 95:1917-1922. doi:10.2105/AJ PH. 2004.058859)

Objectives. The purpose of the study was to conduct a national multivariate analysis on poverty-area residence and mortality in the United States. Methods. Proportional hazards analyses were performed of the effect of poverty-area residence on the risk of mortality among adult examinees in the 1971 through 1974 National Health and Nutrition Examination Survey who were followed through 1987. Results. Poverty-area residence was associated with significantly elevated risk of all-cause mortality (rate ratio = 1.78, 95% confidence interval = 1.33, 2.38) and some cause-specific mortality among those aged 25 through 54 years, but not among those aged 55 through 74 years, at baseline after adjustment for several individual and household characteristics. Conclusions. Residence in poverty areas contributes to socioeconomic gradients in mortality among nonelderly adults in the United States. (Am J Public Health. 1998;88:973-976)

Objectives. The purpose of this study was to compare the economic costs and benefits of fortifying grain with folic acid to prevent neural tube defects. Methods. A cost-benefit analysis based on the US population, using the human capital approach to estimate the costs associated with preventable neural tube defects, was conducted. Results. Under a range of assumptions about discount rates, baseline folate, intake, the effectiveness of folate in preventing neural tube defects, the threshold dose that minimizes risk, and the cost of surveillance, fortification would likely yield a net economic benefit. The best estimate of this benefit is $94 million with low-level (140 micrograms [mcg] per 100 g grain) fortification and $252 million with high-level (350 mcg/100 g) fortification. The benefitto-cost ratio is estimated at 4.3:1 for low-level and 6.1:1 for high-level fortification. Conclusions. By averting costly birth defects, folic acid fortification of grain in the United States may yield a substantial economic benefit. We may have underestimated net benefits because of unmeasured costs of neural tube defects and unmeasured benefits of higher folate intake. We may have overestimated net benefits if the cost of neurologic sequelae related to delayed diagnosis of vitamin B(12) deficiency exceeds our projection. (Am J Public Health. 1995;85:667-676), Fortifying cereal grains with folic acid may prevent costly birth defects such as spina bifida and anencephaly. Neural tube closure defects have been linked to folic acid deficiencies. Grain enrichment at 140 mcg would enable females 11 to 50 years old to receive in excess of 400 mcg daily from food and supplement sources. A net benefit of $94 million with this level of fortification is estimated. A high level of fortification at 350 mcg would save $252 million. Benefit-to-cost ratios for low-level folate enrichment are calculated at 4.3:1 and 6.1:1 for high-level enrichment. Because most women of childbearing consume cereal, fortification would reach them. Folic acid has no known adverse health effects, except for people with undiagnosed pernicious anemia and those taking anticonvulsant or antifolate medications.

Objectively. This study was undertaken to examine how the interaction between occupational class transitions and race affects the incidence of hypertension. Methods. A cohort of 1982 men (183 Black), ages 25 to 55, received a baseline medical exam between 1971 and 1975 and a follow-up between 1982 and 1984. Logistic regressions were estimated for hypertension at follow-up controlling for hypertension at baseline, other risk factors associated with blood pressure, and interaction terms identifying specific occupational class transitions among Blacks and Whites. The occupational class matrix was based largely on scores of US Census Bureau occupations from the Dictionary of Occupational Titles. Results. Relative to Whites who remained in professional and technical jobs between baseline and follow-up, Blacks and Whites who remained in lower occupational classes or made specific transitions--notably into the lowest class--had significantly higher incidence rates of hypertension. These differences were greater among Blacks, who are also more concentrated in and less likely to move upward from the lower end of the occupational class matrix. Conclusions. Widening racial disparities in high blood pressure over the period of study may be partly attributable to characteristics associated with occupational class position and dynamics. (Am J Public Health. 1994;84:945-950), Differences between blacks and whites in the incidence of hypertension may be partly due to differences in occupational attainment. Hypertension is chronic high blood pressure. A group of 1,982 men aged 25 to 55, of whom 183 were black, had a baseline medical exam between 1971 and 1975 and another exam between 1982 and 1984. They were grouped into four occupational groups with class 1 being occupations that were secure, paid well, and allowed advancement and independent decision-making, and class 4 being none of the above. Those who stayed in classes 3 and 4 as well as those who moved from higher classes to class 3 or 4 over the time period of the study were more likely to have hypertension compared with those who stayed in class 1. Blacks were more heavily concentrated in classes 3 and 4 and were less likely to move upward over the time period of the study.

Objectives: Ethnic and racial health disparities have been well-documented in the scholarly literature. In recent years, evidence about time spent in physical (in)activity and its relationship to physical and mental health has also emerged. This study assesses if observed ethnic/racial health differences were associated with differences in time use. Design: Our analyses utilized baseline data from 510 Utah women who enrolled in one of two community-based, participatory research intervention studies between 2012 and 2015. The distinct racial/ethnic groups included African immigrants, African Americans, Latinas, Native Hawaiians/Pacific Islanders, American Indians/Alaskan Natives, and rural White, Non-Latina women. In the baseline survey, respondents reported the typical time they spent in paid employment, television/movie viewing, physical activity, food preparation/clean-up, and sleep. Cluster analysis was used to identify seven distinct patterns of time use within these five activities. We related these time use patterns along with race/ethnicity, socio-demographics, and other potentially contributing health-related factors (e.g. smoking status) to two health outcomes: (1) self-reported health status, and (2) depression. Results: Our time use clusters revealed heterogeneity by racial/ethnic groups, suggesting that some of the health effects that may have been previously ascribed to group membership should instead be attributed to (un)healthy patterns of time use. In particular, spending too much time in sedentary activities such as watching television/movies and too little time sleeping both linked to poor physical and mental health, independently of racial/ethnic group membership. Conclusions: Researchers and policy makers designing culturally sensitive physical activity health-related interventions should consider patterns of time use that are associated with poor health. Programs designed to improve sleep time and reduce sedentary television-viewing time may be as important as interventions designed to increase physical activity time. These broader patterns of time use mediated the relationships between race/ethnicity and physical and mental health for the women in our study. [ABSTRACT FROM AUTHOR]