Addressing Challenges to Coordinating the Implementation of Place-Based Chronic Disease Prevention Interventions in Los Angeles

CONTEXT

Chronic disease prevention initiatives have traditionally been structured to address a single disease, potentially limiting the scope of health impacts. In the past decade, initiatives have increasingly adopted a coordinated approach, in which multiple interventions are intended to work synergistically-often in a bounded geographic area-to address interrelated risk factors and diseases. However, despite increased interest in this coordinated approach, few examples exist of how coordination has been operationalized in local public health practice.

IMPLEMENTATION

In 2014, the Los Angeles County Department of Public Health launched the 4-year Chronic Disease Prevention Strategy (CDPS). Through CDPS, the Los Angeles County Department of Public Health implemented a range of environmental, lifestyle change, and health system interventions intended to collectively reduce chronic disease among adults in Los Angeles, with concentrated implementation occurring in 1 high-need neighborhood.

EVALUATION

This case study examined the activities undertaken to coordinate across CDPS interventions and documented challenges to these efforts. Data were collected via a document review of programmatic materials and structured conversations with staff leading implementation of CDPS interventions.

RESULTS

Document review and structured conversations with staff identified 3 primary coordination activities: (1) collaborating on outreach materials to unify messaging, (2) developing a network of common partners, and (3) investing in shared data collection. Operational challenges identified were disparate short-term objectives across interventions, minimal alignment between clinical practice and CDPS goals, restrictions around bidirectional referrals between organizations, and limited bandwidth among new partners to engage with multiple CDPS interventions. Contextual challenges identified were competing social and political issues, and geographic fluidity regarding where community members sought health resources.

CONCLUSION

Developing an initiative-specific coordination plan prior to implementation may help reduce challenges to coordination. Modifications in how health initiatives are funded and structured may be needed: greater flexibility in how funding is administered, and the inclusion of coordination-specific metrics, may enable more robust coordination.

Local School Wellness Policy as a Means to Advance Whole School, Whole Community, Whole Child: Assessing Alignment in Los Angeles County

BACKGROUND

District wellness policies provide an avenue to advance the Whole School, Whole Community, Whole Child (WSCC) model. The extent to which wellness policies currently align with WSCC is unclear; to-date, tools have been unavailable to examine this issue.

METHODS

We reviewed written health-focused policies among 37 school districts in Los Angeles County in 2017 utilizing a 54-item tool designed to examine the quality of policies in the 10 WSCC domains. Descriptive analyses explored overall and domain-specific comprehensiveness and strength; simple negative binomial regression models examined differences in the policy quality and structure by legislated status.

RESULTS

Approximately half of expected policies were present in wellness policies (mean comprehensiveness score = 52.65, ±18.09), < 20% were strong (mean strength score = 16.97, ±8.05). Content in WSCC domains addressed by legislative mandates was significantly more comprehensive and stronger, and more frequently located within the wellness policies, relative to content in non-legislated domains.

CONCLUSIONS

Opportunities exist for better alignment of wellness policies with WSCC. Education and health practitioners can utilize the tool developed for this study to identify priority areas where policy support is needed in their jurisdictions. Additional efforts are needed to help schools facilitate and document practice gains around WSCC-aligned policies.

Evaluating Streetscape Modifications in Los Angeles, California with a Health Lens

Background and Purpose: Despite growing evidence linking health and the built environment, local health departments are often not involved in the evaluation of a streetscape modification project. This paper describes an assessment conducted by a local health department to address this gap by using a health lens to evaluate the installation of painted curb extensions on a commercial corridor in Los Angeles. Methods: The local health department conducted an observational pre-post study of pedestrian and motorist data at both an intersection receiving the painted curb extension and a comparison intersection along the same corridor that had already received the extension. The study also analyzed streetscape features along the corridor related to walkability, to understand the painted curb extension in the context of the broader built environment. Results: The painted curb extension did not appear to significantly impact pedestrian and motorist behavior, though some slight changes were observed. Pedestrians along the corridor generally exhibited safe behavior at intersections, but encountered dangerous driver behavior and built environment barriers, which can discourage walking. Conclusion: This case study demonstrates how health considerations can be integrated into an evaluation of a streetscape modification project, and can provide guidance for other health practitioners developing such evaluation projects in their own jurisdictions.

Understanding the Density and Distribution of Restaurants in Los Angeles County to Inform Local Public Health Practice

INTRODUCTION

To describe the potential reach of restaurant-based strategies that seek to improve the healthfulness of menu options, it is important to understand the local restaurant environment, including the extent to which restaurants subject to policy mandates are located in communities disproportionately affected by diet-related diseases.

METHODS

This cross-sectional study examined the restaurant environment in Los Angeles County, a large jurisdiction with diverse geographic and socioeconomic characteristics, specifically 1) the number and characteristics of restaurants; 2) the association between neighborhood sociodemographics and restaurant density; and 3) the association between neighborhood sociodemographics and restaurant characteristics, including chain status (large chain, small chain, independent restaurant). Data sources were 1) industry data on restaurant location and characteristics (N = 24,292 restaurants) and 2) US Census data on neighborhood sociodemographics (N = 247 neighborhoods). We conducted descriptive and bivariate analyses at the restaurant and neighborhood level.

RESULTS

Countywide, only 26.5% of all restaurants were part of a large chain (a chain with ≥20 locations). We found positive associations between restaurant density and neighborhood proportions of non-Hispanic white residents and residents with more than a high school education. We found limited support to suggest a greater density of large chains in neighborhoods with lower socioeconomic status.

CONCLUSION

Results highlight the potentially limited reach of strategies targeting chain restaurants and point to the importance of including small chain restaurants and independent restaurants in public health efforts to improve the healthfulness of restaurants. Understanding where restaurants are in relation to priority populations is a critical step to planning strategies that address diet-related disparities.

Distribution, characteristics, and level of community awareness and use of formal shared use sites in Los Angeles

Shared use agreements (SUA) could increase opportunities for physical activity (PA) in under-resourced, urban areas. Despite recent investments in SUAs, the extent to which they reach communities in need and the level of community awareness and use of SUAs remains unclear. This cross-sectional study examined: 1) the distribution of SUAs in Los Angeles (LA) during the 2015-2016 academic year, 2) the characteristics of communities where SUAs were located, and 3) the extent to which community members were aware of and using available facilities. Assessment methods included: 1) abstraction of school administrative data reflecting the geographic distribution and scope of SUAs in LA, 2) collation of community-level Census and local planning data to describe demographic characteristics and per capita park acreage of communities where SUAs were located, and 3) collection of data via an Internet panel survey of LA adults (n = 371) examining awareness and use of SUA facilities. Under 3% of schools had a SUA in place during the study period. Compared to other areas of the city, areas within one mile of SUAs had more Hispanic/Latino, low-income, and lower educational status residents. Among survey respondents, 25.6% of those living within one mile of a SUA reported having access to school facilities; 48.6% of those reporting access reported using them. Although potentially targeted in high-needs areas, community members may not be aware of or utilizing SUA facilities. Additional efforts are needed to both expand access to school-based PA resources and attract community users.

Implementing a Healthy Food Distribution Program: A Supply Chain Strategy to Increase Fruit and Vegetable Access in Underserved Areas

Increasing access to fresh produce in small retail venues could improve the diet of people in underserved communities. However, small retailers face barriers to stocking fresh produce. In 2014, an innovative distribution program, Community Markets Purchasing Real and Affordable Foods (COMPRA), was launched in Los Angeles with the aim of making it more convenient and profitable for small retailers to stock fresh produce. Our case study describes the key processes and lessons learned in the first 2 years of implementing COMPRA. Considerable investments in staff capacity and infrastructure were needed to launch COMPRA. Early successes included significant week-to-week increases in the volume of produce distributed. Leveraging partnerships, maintaining a flexible operational and funding structure, and broadly addressing store owners’ needs contributed to initial gains. We describe key challenges and next steps to scaling the program. Lessons learned from implementing COMPRA could inform other jurisdictions considering supply-side approaches to increase access to healthy food.

Review of Education-Focused Health Impact Assessments Conducted in the United States

BACKGROUND

Health impact assessment (HIA) provides a structured process for examining the potential health impacts of proposed policies, plans, programs, and projects. This study systematically reviewed HIAs conducted in the United States on prekindergarten, primary, and secondary education-focused decisions.

METHODS

Relevant HIA reports were identified from web sources in late 2015. Key data elements were abstracted from each report. Four case studies were selected to highlight diversity of topics, methods, and impacts of the assessment process.

RESULTS

Twenty HIAs completed in 2003-2015 from 8 states on issues related to prekindergarten through secondary education were identified. The types of decisions examined included school structure and funding, transportation to and from school, physical modifications to school facilities, in-school physical activity and nutrition, and school discipline and climate. Assessments employed a range of methods to characterize the nature, magnitude, and severity of potential health impacts. Assessments fostered stakeholder engagement and provided health-promoting recommendations, some of which were subsequently incorporated into school policies.

CONCLUSIONS

Health impact assessment is a promising tool that education, health, and other stakeholders can use to maximize the health and well-being of students, families, and communities.

Youth Descriptions of Mental Health Needs and Experiences with School-based Services: Identifying Ways to Meet the Needs of Underserved Adolescents

While schools serve as a common entry point into mental health services for underserved youth, engagement of students in need of care remains a problem. Little is known about the ways schools can best address students' mental health needs, especially from the perspective of youth who struggle to attend school, a vulnerable group with a high burden of mental health problems. A qualitative descriptive approach was used to analyze data from in-depth interviews with a sample of 18 youth with a history of school truancy and mental health problems. Analyses explored how youth expressed mental health symptoms, and their trajectories through, and perceptions of, school-based mental health services. Results suggest that participants experienced multiple, overlapping symptoms; only a portion had their needs addressed. The quality of relationships with school staff and the perceived efficacy of treatment affected service trajectories. Promising school-based approaches to address students' mental health needs are discussed.

Consumer Knowledge, Attitudes, and Behaviors of Sodium Intake and Reduction Strategies in Los Angeles County

Background and Purpose: In Los Angeles County, over 27% of the population has been diagnosed with hypertension and over 60% is considered overweight or obese. To help address the burden of hypertension and other diet-associated diseases, the Los Angeles County Department of Public Health launched its sodium reduction initiative to scale sodium reduction approaches and, ultimately, reduce sodium intake in the region. The purpose of this study was to gain a better understanding of consumer knowledge, attitudes, and behaviors related to sodium consumption and reduction to inform ongoing program efforts. Methods: A cross-sectional Internet panel survey was administered from December 2014 to January 2015 to a panel of Los Angeles County adult residents (n=848). Results: Results suggest low levels of consumer knowledge of recommended daily sodium intake limits (5.9%), high levels of support for reduction of sodium in the food supply (>70%), and moderate levels of healthy behavior change (e.g., 48.1% reported determining their food purchases based on the sodium content, 56.3% reported watching their sodium intake). Conclusions: These findings support the continued need to work at multiple levels (consumer, food supplier/manufacturer, retail) to reduce sodium intake in Los Angeles County.

Access to and Use of Schools for Physical Activity Among Adults in Los Angeles County

Formal agreements that outline conditions for community use of school facilities represent a potentially attractive approach to increasing access to places for physical activity in underresourced areas. Despite growing interest in these shared use agreements, limited data are available on their population-level impacts. This study used data collected via an Internet panel survey in spring 2014 (n = 1,006) to examine the extent of public awareness and use of school-based physical activity resources in Los Angeles County. Weighted data were analyzed using logistic regression to examine associations among access to and use of schools, demographics, and behavioral and environmental factors. Negative binomial regression was performed to test the association between access to school-based physical activity resources and physical activity. Results suggest that a large percentage (57.7%) of people have access to school-based physical activity resources; however, only a portion (30.3%) use them. Safety of school grounds and whether onsite programming was offered were positively associated with use. In light of these findings, additional efforts may be needed to help optimize community use of schools for physical activity. These results can help inform program planning and implementation in communities considering shared use policies.

Self-Efficacy as a Mediator of the Relationship Between the Perceived Food Environment and Healthy Eating in a Low Income Population in Los Angeles County

While previous studies have described psychosocial and environmental factors that contribute to healthy eating, much remains unknown about the interactions between them. We assessed the relationship between the perceived food environment, self-efficacy and fruit and vegetable consumption, using data from a sample of racially diverse, low-income adult clientele of five public health centers in Los Angeles County (n = 1503). We constructed a negative binomial regression model to examine the association between perceived food environment and the number of fruits and vegetables consumed. For every one point increase on the perceived food environment scale, individuals ate about 5% more fruits and vegetables (95% CI 1.007, 1.089), controlling for other covariates. Self-efficacy was shown to be a significant mediator (mediated effect = 0.010; 95% CI 0.002, 0.020), accounting for 22.9% of the effect. Efforts to increase access to healthy options may not only improve eating behaviors, but also influence individuals' beliefs that they can eat healthfully.

The Impact of Two Los Angeles County Teen Courts on Youth Recidivism: Comparing Two Informal Probation Programs

OBJECTIVE

This study sought to examine the impact of two Teen Courts operating in Los Angeles County, a juvenile justice system diversion program in which youth are judged by their peers and given restorative sentences to complete during a period of supervision.

METHODS

A quasi-experimental design was used to compare youth who participated in Teen Court (n=112) to youth who participated in another diversion program administered by the Probation Department (the 654 Contract program) (n=194). Administrative data were abstracted from Probation records for all youth who participated in these programs between January 1, 2012 and June 20, 2014. Logistic and survival models were used to examine differences in recidivism - measured as whether the minor had any subsequent arrest or arrests for which the charge was filed.

RESULTS

Comparison group participants had higher rates of recidivism than Teen Court participants, after controlling for age, gender, race/ethnicity, and risk level. While the magnitude of the program effects were fairly consistent across model specifications (odd ratios comparing Teen Court [referent] to school-based 654 Contract ranging from 1.95 to 3.07, hazard ratios ranging from 1.62 to 2.27), differences were not statistically significant in all scenarios.

CONCLUSIONS

While this study provides modest support for the positive impact of Teen Court, additional research is needed to better understand how juvenile diversion programs can improve youth outcomes.

Dissemination, Implementation, and Improvement Science Research in Population Health: Opportunities for Public Health and CTSAs

IMPORTANCE

The complex, dynamic nature of health systems requires dissemination, implementation, and improvement (DII) sciences to effectively translate emerging knowledge into practice. Although they hold great promise for informing multisector policies and system-level changes, these methods are often not strategically used by public health.

OBJECTIVES AND METHODS

More than 120 stakeholders from Southern California, including the community, federal and local government, university, and health services were convened to identify key priorities and opportunities for public health departments and Clinical and Translational Science Awards programs (CTSAs) to advance DII sciences in population health.

MAIN OUTCOMES

Participants identified challenges (mismatch of practice realities with narrowly focused research questions; lack of iterative learning) and solutions (using methods that fit the dynamic nature of the real world; aligning theories of change across sectors) for applying DII science research to public health problems. Pragmatic steps that public health and CTSAs can take to facilitate DII science research include: employing appropriate study designs; training scientists and practicing professionals in these methods; securing resources to advance this work; and supporting team science to solve complex-systems issues.

CONCLUSIONS

Public health and CTSAs represent a unique model of practice for advancing DII research in population health. The partnership can inform policy and program development in local communities.

Public awareness of and support for infrastructure changes designed to increase walking and biking in Los Angeles County

OBJECTIVE

Policies to promote active transportation are emerging as a best practice to increase physical activity, yet relatively little is known about public opinion on utilizing transportation funds for such investments. This study sought to assess public awareness of and support for investments in walking and biking infrastructure in Los Angeles County.

METHOD

In the fall of 2013, the Los Angeles County Department of Public Health conducted a telephone survey with a random sample of registered voters in the region. The survey asked respondents to report on the presence and importance of walking and biking infrastructure in their community, travel behaviors and preferences, and demographics.

RESULTS

One thousand and five interviews were completed (response rate 20%, cooperation rate 54%). The majority of participants reported walking, biking, and bus/rail transportation investments as being important. In addition, participants reported a high level of support for redirecting transportation funds to active transportation investment - the population average was 3.28 (between 'strongly' and 'somewhat' support) on a 4 point Likert scale.

CONCLUSION

Voters see active transportation infrastructure as being very important and support redirecting funding to improve the infrastructure. These findings can inform policy-decisions and planning efforts in the jurisdiction.

What menu changes do restaurants make after joining a voluntary restaurant recognition program?

Programs that recognize restaurants for offering healthful options have emerged as a popular strategy to address the obesity epidemic; however, program fidelity and business responses to such programs are rarely assessed. This study sought to examine how retail restaurants in Los Angeles County chose to comply with participation criteria required by the Choose Health LA Restaurants initiative in the region; the program recognizes restaurants for offering reduced-size portions and healthy children's meals. Menus of all restaurants that joined within 1 year of program launch (n = 17 restaurant brands) were assessed for changes. Nine of the 17 brands made changes to their menus to meet participation criteria for reduced-size portions while 8 of the 10 restaurant brands that offered children's menus made changes to improve the healthfulness of children's meals. Results of this comparative assessment lend support to restaurant compliance with program criteria and menu improvements, even though they are voluntary, representing an important step toward implementing this strategy in the retail environment.

Student receptivity to new school meal offerings: assessing fruit and vegetable waste among middle school students in the Los Angeles Unified School District

OBJECTIVE

We sought to characterize student receptivity to new menu offerings in the Los Angeles Unified School District by measuring the levels of fruit and vegetable waste after implementation of changes to the school lunch menu in fall 2011.

METHODS

We measured waste at four randomly selected middle schools in the school district, using two sources: a) food prepared and left over after service (production waste); and b) food that was selected but not eaten by students (plate waste).

RESULTS

10.2% of fruit and 28.7% of vegetable items prepared at the four schools were left over after service. Plate waste data, collected from 2228 students, suggest that many of them did not select fruit (31.5%) or vegetable (39.6%) items. Among students who did, many threw fruit and vegetable items away without eating a single bite.

CONCLUSIONS

Our findings suggest that fruit and vegetable waste was substantial and that additional work may be needed to increase student selection and consumption of fruit and vegetable offerings. Complementary interventions to increase the appeal of fruit and vegetable options may be needed to encourage student receptivity to these healthier items in the school meal program.

Assessing the connection between health and education: identifying potential leverage points for public health to improve school attendance

OBJECTIVES

We examined multiple variables influencing school truancy to identify potential leverage points to improve school attendance.

METHODS

A cross-sectional observational design was used to analyze inner-city data collected in Los Angeles County, California, during 2010 to 2011. We constructed an ordinal logistic regression model with cluster robust standard errors to examine the association between truancy and various covariates.

RESULTS

The sample was predominantly Hispanic (84.3%). Multivariable analysis revealed greater truancy among students (1) with mild (adjusted odds ratio [AOR] = 1.57; 95% confidence interval [CI] = 1.22, 2.01) and severe (AOR = 1.80; 95% CI = 1.04, 3.13) depression (referent: no depression), (2) whose parents were neglectful (AOR = 2.21; 95% CI = 1.21, 4.03) or indulgent (AOR = 1.71; 95% CI = 1.04, 2.82; referent: authoritative parents), (3) who perceived less support from classes, teachers, and other students regarding college preparation (AOR = 0.87; 95% CI = 0.81, 0.95), (4) who had low grade point averages (AOR = 2.34; 95% CI = 1.49, 4.38), and (5) who reported using alcohol (AOR = 3.47; 95% CI = 2.34, 5.14) or marijuana (AOR = 1.59; 95% CI = 1.06, 2.38) during the past month.

CONCLUSIONS

Study findings suggest depression, substance use, and parental engagement as potential leverage points for public health to intervene to improve school attendance.

A Mixed-Methods Evaluation of the Choose Less, Weigh Less Portion Size Health Marketing Campaign in Los Angeles County

PURPOSE

To assess the impact of the Choose Less, Weigh Less portion size health marketing campaign.

DESIGN

A mixed-methods, cross-sectional evaluation.

SETTING

A quantitative Internet panel survey was administered through an online sampling vendor and qualitative interviews were conducted by street intercept.

SUBJECTS

The panel survey included 796 participants, weighted to represent Los Angeles County. Street intercept interviews were conducted with 50 other participants.

INTERVENTION

The Choose Less, Weigh Less campaign included print media on transit shelters, bus and rail cars, and billboards; radio and online advertising; and Web site content and social media outreach.

MEASURES

The panel survey measured self-reported campaign exposure and outcomes, including knowledge of recommended daily calorie limits, attitudes toward portion sizes, and intent to reduce calories and portion size. Intercept interviews assessed campaign appeal, clarity, and utility.

ANALYSIS

Weighted survey data were analyzed using logistic regression to assess the association between campaign exposure and outcomes. Interview data were analyzed for themes.

RESULTS

The campaign reached 19.7% of the Los Angeles County population. Significant differences were seen for 2 of the 10 outcomes assessed. Participants who saw the campaign were more likely than those who did not to report fast-food portion sizes as being too large (adjusted odds ratio [Adj. OR]: 1.89; 95% confidence interval [CI]: 1.16, 3.07) and intention to choose a smaller portion (Adj. OR: 1.99; 95% CI: 1.20, 3.31). Qualitative data revealed three themes about appeal, clarity, and utility.

CONCLUSION

Health marketing efforts targeting portion size can have relatively broad reach and limited but positive impacts on consumer attitudes and intent to select smaller portions.

Relationship Between Nutritional Knowledge and the Amount of Sugar-Sweetened Beverages Consumed in Los Angeles County

Although consumption of sugar-sweetened beverages (SSBs) is associated with many negative health outcomes, including obesity, diabetes, and cardiovascular disease, the relationship between consumer nutritional knowledge and the amount consumed is poorly understood. The objective of this study was to examine the relationship between knowledge of daily calorie recommendations and the amount of SSBs consumed in a large, economically and racially diverse sample of adults recruited at selected Metro subway and bus shelters in Los Angeles County. In June 2012, the Los Angeles County Department of Public Health conducted street intercept surveys to assess food attitudes and consumption behaviors and public opinions related to a recent 8-week health marketing campaign targeting SSB consumption. Descriptive and comparative analyses were conducted, including a negative binomial regression model, to examine the relationship between knowledge of the daily calorie recommendations and the amount of SSBs consumed. Among survey respondents ( n = 1,041), less than one third correctly identified the daily calorie recommendations for a typical adult. After controlling for sociodemographics and weight status, respondents who correctly identified recommended calorie needs reported, on average, drinking nine fewer SSBs per month than respondents who did not. Results suggest that efforts to reduce SSB consumption might benefit from the inclusion of educational interventions that empower consumers to make healthy choices.

Integrating sodium reduction strategies in the procurement process and contracting of food venues in the County of Los Angeles government, 2010-2012

Since sodium is ubiquitous in the food supply, recent approaches to sodium reduction have focused on increasing the availability of lower-sodium products through system-level and environmental changes. This article reviews integrated efforts by the Los Angeles County Sodium Reduction Initiative to implement these strategies at food venues in the County of Los Angeles government. The review used mixed methods, including a scan of the literature, key informant interviews, and lessons learned during 2010-2012 to assess program progress. Leveraging technical expertise and shared resources, the initiative strategically incorporated sodium reduction strategies into the overall work plan of a multipartnership food procurement program in Los Angeles County. To date, 3 County departments have incorporated new or updated nutrition requirements that included sodium limits and other strategies. The strategic coupling of sodium reduction to food procurement and general health promotion allowed for simultaneous advancement and acceleration of the County's sodium reduction agenda.

The “Sugar Pack” Health Marketing Campaign in Los Angeles County, 2011-2012

As part of a comprehensive approach to combating the obesity epidemic, the Los Angeles County Department of Public Health launched the “Sugar Pack” health marketing campaign in fall 2011. Carried out in three stages, the campaign sought to educate and motivate the public to reduce excess calorie intake from sugar-sweetened beverage consumption. The primary Sugar Pack creative concepts provided consumers with information about the number of sugar packs contained in sugary drinks. Data from formative market research as well as lessons from previous campaigns in other U.S. jurisdictions informed the development of the materials. These materials were disseminated through a multipronged platform that included paid outdoor media on transit and billboards and messaging using social media (i.e., Twitter, Facebook, YouTube, and sendable e-cards). Initial findings from a postcampaign assessment indicate that the Sugar Pack campaign reached broadly into targeted communities, resulting in more than 515 million impressions. Lessons learned from the campaign suggest that employing health marketing to engage the public can lead to increased knowledge, favorable recognition of health messages, and self-reported intention to reduce sugar-sweetened beverage consumption, potentially complementing other obesity prevention strategies in the field.

Estimating the potential health impact and costs of implementing a local policy for food procurement to reduce the consumption of sodium in the county of Los Angeles

OBJECTIVES

We examined approaches to reduce sodium content of food served in settings operated or funded by the government of the County of Los Angeles, California.

METHODS

We adapted health impact assessment methods to mathematically simulate various levels of reduction in the sodium content of food served by the County of Los Angeles and to estimate the reductions' potential impacts on mean systolic blood pressure (SBP) among food-service customers. We used data provided by county government food-service vendors to generate these simulations.

RESULTS

Our analysis predicted that if the postulated sodium-reduction strategies were implemented, adults would consume, on average, 233 fewer milligrams of sodium each day. This would correspond to an average decrease of 0.71 millimeters of mercury in SBP among adult hypertensives, 388 fewer cases of uncontrolled hypertension in the study population, and an annual decrease of $629,724 in direct health care costs.

CONCLUSIONS

Our findings suggest that a food-procurement policy can contribute to positive health and economic effects at the local level. Our approach may serve as an example of sodium-reduction analysis for other jurisdictions to follow.

Barriers and facilitators to implementing primary stroke center policy in the United States: results from 4 case study states

OBJECTIVES

We identified barriers and facilitators to the state-level implementation of primary stroke center (PSC) policies, which encourage the certification or designation of specialized stroke treatment facilities and may address concerns such as transportation bypass, telemedicine, and treatment protocols.

METHODS

We studied the experiences of 4 states (Florida, Massachusetts, New Mexico, and New York) selected from the 18 states that had enacted PSC policies or were actively considering doing so. We conducted semistructured interviews during fieldwork in each case study state.

RESULTS

Our results showed that system fragmentation, gaps in human and financial resources, and complexity at the interorganizational and operational levels are common barriers and that policy champions, stakeholder support and communication, and operational adaptation are essential facilitators in the adoption and implementation of PSC policies.

CONCLUSIONS

The identification of barriers and facilitators reveals the contextual elements that can help or hinder policy implementation and may be useful in informing policy formulation and implementation in other jurisdictions. Proactively identifying jurisdictional challenges and opportunities may help facilitate the policy process for PSC designation and allow jurisdictions to develop more effective stroke systems of care.

A competency-based approach to expanding the cancer care workforce: proof of concept

As part of an effort to address shortages in the cancer workforce, C-Change developed competency standards and logic model-driven implementation tools for strengthening the cancer knowledge and skills of non-oncology health professionals. Testing of these standards and tools at four diverse pilot sites yielded very promising results.