Initial weight loss and early intervention adherence predict long-term weight loss during the Promoting Successful Weight Loss in Primary Care in Louisiana lifestyle intervention

OBJECTIVE

This study tested whether initial weight change (WC), self-weighing, and adherence to the expected WC trajectory predict longer-term WC in an underserved primary-care population with obesity.

METHODS

Data from the intervention group (n = 452; 88% women; 74% Black; BMI 37.3 kg/m2 [SD: 4.6]) of the Promoting Successful Weight Loss in Primary Care in Louisiana trial were analyzed. Initial (2-, 4-, and 8-week) percentage WC was calculated from baseline clinic weights and daily at-home weights. Weights were considered adherent if they were on the expected WC trajectory (10% at 6 months with lower [7.5%] and upper [12.5%] bounds). Linear mixed-effects models tested whether initial WC and the number of daily and adherent weights predicted WC at 6, 12, and 24 months.

RESULTS

Percentage WC during the initial 2, 4, and 8 weeks predicted percentage WC at 6 (R2  = 0.15, R2  = 0.28, and R2  = 0.50), 12 (R2  = 0.11, R2  = 0.19, and R2  = 0.32), and 24 (R2  = 0.09, R2  = 0.11, and R2  = 0.16) months (all p < 0.01). Initial daily and adherent weights were significantly associated with WC as individual predictors, but they only marginally improved predictions beyond initial weight loss alone in multivariable models.

CONCLUSIONS

These results highlight the importance of initial WC for predicting long-term WC and show that self-weighing and adherence to the expected WC trajectory can improve WC prediction.

Regional Research-Practice-Policy Partnerships in Response to Climate-Related Disparities: Promoting Health Equity in the Pacific

Although climate change poses a threat to health and well-being globally, a regional approach to addressing climate-related health equity may be more suitable, appropriate, and appealing to under-resourced communities and countries. In support of this argument, this commentary describes an approach by a network of researchers, practitioners, and policymakers dedicated to promoting climate-related health equity in Small Island Developing States and low- and middle-income countries in the Pacific. We identify three primary sets of needs related to developing a regional capacity to address physical and mental health disparities through research, training, and assistance in policy and practice implementation: (1) limited healthcare facilities and qualified medical and mental health providers; (2) addressing the social impacts related to the cooccurrence of natural hazards, disease outbreaks, and complex emergencies; and (3) building the response capacity and resilience to climate-related extreme weather events and natural hazards.

Engaging LGBTQ Communities in Community-Partnered Participatory Research: Lessons from the Resilience Against Depression Disparities Study

BACKGROUND

The Resilience Against Depression Disparities (RADD), a community partnered, randomized comparative effectiveness study, aimed to address mental health in Lesbian, Gay, Bisexual, Transgender, and Queer/Questioning (LGBTQ) racial/ethnic populations in New Orleans and Los Angeles.

OBJECTIVES

To describe engagement methods, lessons learned, and recommendations in engaging LGBTQ individuals and agencies throughout the RADD study.

METHODS

RADD used a community partnered participatory research framework to engage LGBTQ community members and agencies. Observational and quantitative data were collected to describe engagement activities and study adaptations from October 2016 to May 2019.

RESULTS

Our partnered approach resulted in multiple study adaptations. The principles of cultural humility, coleadership, and addressing health determinants were important to successful engagement with LGBTQ community members and study participants. We recommend maintaining cultural humility as the tenant of all research activities.

CONCLUSIONS

This project's engagement plan demonstrates that community-academic partnerships can be forged to create and modify existing study models for LGBTQ communities.

Mental Health Community and Health System Issues in COVID-19: Lessons from Academic, Community, Provider and Policy Stakeholders

The coronavirus pandemic of 2019 (COVID-19) has created unprecedented changes to everyday life for millions of Americans due to job loss, school closures, stay-at-home orders and health and mortality consequences. In turn, physicians, academics, and policymakers have turned their attention to the public mental health toll of COVID-19. This commentary reporting from the field integrates perceptions of academic, community, health system, and policy leaders from state, county, and local levels in commenting on community mental health needs in the COVID-19 pandemic. Stakeholders noted the broad public health scope of mental health challenges while expressing concern about exacerbation of existing disparities in access and adverse social determinants, including for communities with high COVID-19 infection rates, such as African Americans and Latinos. They noted rapid changes toward telehealth and remote care, and the importance of understanding impacts of changes, including who may benefit or have limited access, with implications for future services delivery. Needs for expanded workforce and training in mental health were noted, as well as potential public health value of expanding digital resources tailored to local populations for enhancing resilience to stressors. The COVID-19 pandemic has led to changes in delivery of health care services across populations and systems. Concerns over the mental health impact of COVID-19 has enhanced interest in remote mental care delivery and preventive services, while being mindful of potential for enhanced disparities and needs to address social determinants of health. Ongoing quality improvement across systems can integrate lessons learned to enhance a public mental well-being.

Weight Loss in Underserved Patients - A Cluster-Randomized Trial

BACKGROUND

Evidence of the effectiveness of treatment for obesity delivered in primary care settings in underserved populations is lacking.

METHODS

We conducted a cluster-randomized trial to test the effectiveness of a high-intensity, lifestyle-based program for obesity treatment delivered in primary care clinics in which a high percentage of the patients were from low-income populations. We randomly assigned 18 clinics to provide patients with either an intensive lifestyle intervention, which focused on reduced caloric intake and increased physical activity, or usual care. Patients in the intensive-lifestyle group participated in a high-intensity program delivered by health coaches embedded in the clinics. The program consisted of weekly sessions for the first 6 months, followed by monthly sessions for the remaining 18 months. Patients in the usual-care group received standard care from their primary care team. The primary outcome was the percent change from baseline in body weight at 24 months.

RESULTS

All 18 clinics (9 assigned to the intensive program and 9 assigned to usual care) completed 24 months of participation; a median of 40.5 patients were enrolled at each clinic. A total of 803 adults with obesity were enrolled: 452 were assigned to the intensive-lifestyle group, and 351 were assigned to the usual-care group; 67.2% of the patients were Black, and 65.5% had an annual household income of less than $40,000. Of the enrolled patients, 83.4% completed the 24-month trial. The percent weight loss at 24 months was significantly greater in the intensive-lifestyle group (change in body weight, -4.99%; 95% confidence interval [CI], -6.02 to -3.96) than in the usual-care group (-0.48%; 95% CI, -1.57 to 0.61), with a mean between-group difference of -4.51 percentage points (95% CI, -5.93 to -3.10) (P<0.001). There were no significant between-group differences in serious adverse events.

CONCLUSIONS

A high-intensity, lifestyle-based treatment program for obesity delivered in an underserved primary care population resulted in clinically significant weight loss at 24 months. (Funded by the Patient-Centered Outcomes Research Institute and others; PROPEL ClinicalTrials.gov number, NCT02561221.).

Preparedness and Community Resilience in Disaster-Prone Areas: Cross-Sectoral Collaborations in South Louisiana, 2018

Objectives. To determine how community-based organizations (CBOs) define priorities for bolstering community resilience, challenges in addressing these priorities, and strategies to address challenges.Methods. The Community Resilience Learning Collaborative and Research Network (C-LEARN) is a multiphase study examining opportunities to improve community resilience to the threats of disaster and climate change in South Louisiana. Phase I of C-LEARN involved using the National Health Security Strategy and Implementation Plan for directed content analysis of key informant interviews with CBO representatives from 47 agencies within South Louisiana between February and May 2018.Results. CBO interviewees highlighted the importance of forging relationships and building trust through diverse cross-sector collaborations and partnerships before disasters. Such collaborations and partnerships were shown to tailor disaster response to the needs of particular communities and populations as well as address key challenges such as gaps in information, services, and resources.Conclusions. Our results encourage a culture of community resilience and community preparedness through partnerships and community-engaged strategies. C-LEARN will utilize the results of our interviews in the design of phase II of our agency-level coalition-building intervention.

Creating Safe Spaces: A Community Health Worker-Academic Partnered Approach to Addressing Intimate Partner Violence

Intimate partner violence (IPV) is a persistent public health problem in the United States, with an estimated one in three women experiencing rape, physical violence, and/or stalking by an intimate partner within her lifetime. Non-Hispanic Black women disproportionately experience IPV, but there has been limited success in implementing culturally appropriate prevention programs and services for members of this population. Community health workers (CHWs) are trusted members of under-resourced communities who provide reliable health information and improve the cultural appropriateness of service delivery and may be a vital resource for developing new IPV interventions. Guided by the principles of community partnered participatory research, we developed the CHW-led Safe Spaces project, which aimed to establish a strong academic-community partnership to focus on issues related to experiences of IPV and the prevention of IPV in New Orleans. In this article, we describe the development of our partnership including the formation of an advisory board, creation of a broad-based stakeholder coalition, offering a community partnered participatory research training, conducting IPV education and outreach, and establishing a research agenda. Our processes are replicable and lessons learned may be relevant to other groups seeking to address IPV by leveraging the strengths of community-academic collaborations and CHWs.

The Community and Patient Partnered Research Network (CPPRN): Application of Patient-Centered Outcomes Research to Promote Behavioral Health Equity

Objective

We describe the rationale, development, and progress on the Community and Patient Partnered Research Network (CPPRN). The CPPRN builds on more than a decade of partnered work and is designed to promote health equity by developing partnered research on behavioral health and social risk factors in Los Angeles and New Orleans.

Setting

A community-academic partnership across Los Angeles County and New Orleans.

Methods

Review of rationale, history, structure, activities and progress in applying community partnered participatory research (CPPR) to CPPRN.

Findings

Patient and community stakeholders participated in all phases of development, including local and national activities. Key developments include partnered planning efforts, progress on aggregating a large, de-identified dataset across county agencies, and development of an information technology-supported screening approach for behavioral and social determinants in health care, social, and community-based settings.

Conclusion

The CPPRN represents a promising approach for research data networks, balancing the potential benefit of information technology and data analytic approaches while addressing potential risks and priorities of relevant stakeholders.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions

Significance

Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown.

Objective

To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups.

Design

Secondary analyses of a cluster-randomized trial.

Setting

93 health care and community-based programs in two neighborhoods.

Participants

Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys.

Intervention

CEP or RS for implementing depression quality improvement programs.

Outcomes and Analyses

Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory).

Results

Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC.

Conclusions

CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

Promoting Successful Weight Loss in Primary Care in Louisiana (PROPEL): Rationale, design and baseline characteristics

Underserved and minority populations suffer from a disproportionately high prevalence of obesity and related comorbidities. Effective obesity treatment programs delivered in primary care that produce significant weight loss are currently lacking. The purpose of this trial is to test the effectiveness of a pragmatic, high intensity lifestyle-based obesity treatment program delivered within primary care among an underserved population. We hypothesize that, relative to patients who receive usual care, patients who receive a high-intensity, health literacy- and culturally-appropriate lifestyle intervention will have greater percent reductions in body weight over 24 months. Eighteen clinics (N = 803 patients) serving low income populations with a high proportion of African Americans in Louisiana were randomized to the intervention or usual car. Patients in the intervention participate in a high-intensity lifestyle program delivered by health coaches employed by an academic health center and embedded in the primary care clinics. The program consists of weekly (16 in-person/6 telephone) sessions in the first six months, followed by sessions held at least monthly for the remaining 18 months. Primary care practitioners in usual care receive information on weight management and the current Centers for Medicare and Medicaid Services reimbursement for obesity treatment. The primary outcome is percent weight loss at 24 months. Secondary outcomes include absolute 24-month changes in body weight, waist circumference, blood pressure, fasting glucose and lipids, health-related quality of life, and weight-related quality of life. The results will provide evidence on the effectiveness of implementing high-intensity lifestyle and obesity counseling in primary care settings among underserved populations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier NCT02561221.

Comparative Effectiveness of Coalitions Versus Technical Assistance for Depression Quality Improvement in Persons with Multiple Chronic Conditions

SIGNIFICANCE

Prior research suggests that Community Engagement and Planning (CEP) for coalition support compared with Resources for Services (RS) for program technical assistance to implement depression quality improvement programs improves 6- and 12-month client mental-health related quality of life (MHRQL); however, effects for clients with multiple chronic medical conditions (MCC) are unknown.

OBJECTIVE

To explore effectiveness of CEP vs RS in MCC and non-MCC subgroups.

DESIGN

Secondary analyses of a cluster-randomized trial.

SETTING

93 health care and community-based programs in two neighborhoods.

PARTICIPANTS

Of 4,440 clients screened, 1,322 depressed (Patient Health Questionnaire, PHQ8) provided contact information, 1,246 enrolled and 1,018 (548 with ≥3 MCC) completed baseline, 6- or 12-month surveys.

INTERVENTION

CEP or RS for implementing depression quality improvement programs.

OUTCOMES AND ANALYSES

Primary: depression (PHQ9 <10), poor MHRQL (Short Form Health Survey, SF-12<40); Secondary: mental wellness, good physical health, behavioral health hospitalization, chronic homelessness risk, work/workloss days, services use at 6 and 12 months. End-point regressions were used to estimate intervention effects on outcomes for subgroups with ≥3 MCC, non-MCC, and intervention-by-MCC interactions (exploratory).

RESULTS

Among MCC clients at 6 months, CEP vs RS lowered likelihoods of depression and poor MHRQL; increased likelihood of mental wellness; reduced work-loss days among employed and likelihoods of ≥4 behavioral-health hospitalization nights and chronic homelessness risk, while increasing faith-based and park community center depression services; and at 12 months, likelihood of good physical health and park community center depression services use (each P<.05). There were no significant interactions or primary outcome effects for non-MCC.

CONCLUSIONS

CEP was more effective than RS in improving 6-month primary outcomes among depressed MCC clients, without significant interactions.

Resident physicians' opinions and behaviors regarding the use of interpreters in New Orleans

OBJECTIVES

In academic medical centers, resident physicians are most involved in the care of patients, yet many have little training in the proper use of interpreters in the care of patients with limited English-language proficiency. Residents have cited lack of time and lack of access to trained medical interpreters as barriers to the use of professional interpreter services. The purpose of this study was to examine the usage patterns of interpreters and perceived barriers to using interpreters in New Orleans.

METHODS

Subjects included resident physicians training in internal medicine, pediatrics, and combined internal medicine and pediatrics at Tulane University and Louisiana State University in New Orleans. A survey that consisted of demographics, short-answer, and Likert-scale questions regarding attitudes related to the use of interpreters was used as the metric.

RESULTS

The overall response rate was 55.5%. A total of 92.4% of subjects surveyed stated that they had used an interpreter during their residency. Telephone services and family members were the most commonly used types of interpreters (41.3% and 30.5%, respectively). Resident physicians were most likely to use interpreter services during their initial history taking as well as at discharge, but use declined throughout patients' hospitalization (P < 0.001). Residents cited lack of availability, lack of time, and lack of knowledge about accessing interpreter services as the major barriers to using interpreters.

CONCLUSIONS

Resident physicians training in New Orleans have experience using interpreter services; however, they continue to use untrained interpreters and use varies during the hospital encounter. Targeted training for residents, including interpreter logistics, may help increase the use of interpreters.

Videovoice: community assessment in post-Katrina New Orleans

This study describes a videovoice project implemented in post-Katrina New Orleans during a pivotal time in city rebuilding and revitalization. Videovoice is a health advocacy, promotion, and research method through which people get behind video cameras to research issues of concern, communicate their knowledge, and advocate for change. Using videovoice method, a community-academic-filmmaker partnership engaged 10 Central City neighbors, who took part in an 18-week training and community assessment. The resulting 22-min film premiered before more than 200 city leaders and residents, reached more than 4,000 YouTube viewers during its first 2 months online, and was shared through the distribution of 1,000 DVDs. Viewing further helped mobilize the community for action on three priority issues: affordable housing, education, and economic development. Challenges in using videovoice, including privacy issues and cost considerations in a resource-poor community, are discussed. Despite such challenges, this method may provide community-academic partnerships with the opportunity to equitably engage in research, produce independent media, and mobilize for action.

Capacity Building for Post-Disaster Mental Health since Katrina: The Role of Community Health Workers

The floods and devastation of Hurricanes Katrina and Rita contributed to socioeconomic instability and psychosocial trauma for the affected communities and populations, significantly for people of limited economic means and persons of color. Though more than 1/3 of the adult population from impacted areas experienced significant psychological distress, few people had access to or received appropriate health or mental health services in the months and years that followed. Community health workers (CHWs)—defined as lay community members whose backgrounds are similar to those for whom they provide such services as culturally relevant health education, individual- and community-level advocacy, and links to the health care system— may represent a particularly promising workforce strategy to increase access to quality mental health services and overcome racial and ethnic disparities in care. In this paper, we briefly review a post-disaster mental health training program for CHWs from the greater New Orleans area. We present preliminary evidence that CHWs remain engaged in addressing post-disaster concerns, and that there is community support for further CHW education. We discuss implications for CHW participation in recovery from future disasters and we highlight the work of Cynthia Carriere, a CHW from the Lower 9th Ward in New Orleans.

Treatment research for children and youth exposed to traumatic events: moving beyond efficacy to amp up public health impact

OBJECTIVE

Population-based demands for trauma services have accelerated interest in the rapid deployment of efficacious interventions to address the diverse mental health consequences of traumatic experiences. However, optimal strategies for supporting either implementation or dissemination of trauma-focused interventions within healthcare or mental healthcare systems are underdeveloped.

METHODS

This work offers suggestions for adapting treatment research parameters in order to advance the science on the implementable and practical use of trauma-focused interventions within a public health framework. To this end, we briefly examine the current status of research evidence in this area and discuss efficacy and effectiveness treatment research parameters with specific attention to the implications for developing the research base on the implementation and dissemination of effective trauma practices for children and adolescents.

RESULTS

Examples from current studies are used to identify approaches for developing, testing and enhancing strategies to roll out effective treatment practices in real-world settings.

CONCLUSIONS

New approaches that reflect the contexts in which these practices are implemented may enhance the feasibility, acceptability, replicability and sustainability of trauma treatments and services, and thus improve outcomes for a broader population of youth and families.

Promoting mental health recovery after hurricanes Katrina and Rita: what can be done at what cost

CONTEXT

Concerns about mental health recovery persist after the 2005 Gulf storms. We propose a recovery model and estimate costs and outcomes.

OBJECTIVE

To estimate the costs and outcomes of enhanced mental health response to large-scale disasters using the 2005 Gulf storms as a case study.

DESIGN

Decision analysis using state-transition Markov models for 6-month periods from 7 to 30 months after disasters. Simulated movements between health states were based on probabilities drawn from the clinical literature and expert input.

SETTING

A total of 117 counties/parishes across Louisiana, Mississippi, Alabama, and Texas that the Federal Emergency Management Agency designated as eligible for individual relief following hurricanes Katrina and Rita.

PARTICIPANTS

Hypothetical cohort, based on the size and characteristics of the population affected by the Gulf storms. Intervention Enhanced mental health care consisting of evidence-based screening, assessment, treatment, and care coordination.

MAIN OUTCOME MEASURES

Morbidity in 6-month episodes of mild/moderate or severe mental health problems through 30 months after the disasters; units of service (eg, office visits, prescriptions, hospital nights); intervention costs; and use of human resources.

RESULTS

Full implementation would cost $1133 per capita, or more than $12.5 billion for the affected population, and yield 94.8% to 96.1% recovered by 30 months, but exceed available provider capacity. Partial implementation would lower costs and recovery proportionately.

CONCLUSIONS

Evidence-based mental health response is feasible, but requires targeted resources, increased provider capacity, and advanced planning.