Allen Cheadle

Operational Definitions of Walkable Neighborhood: Theoretical and Empirical Insights

BACKGROUND The concept of walkable neighborhoods is increasingly important in physical activity research and intervention. However, limited theoretical understanding and measurable definitions remain a challenge. METHODS This paper reviews theories defining neighborhoods and offers an empirical approach to identify measurable attributes and thresholds of walkable neighborhoods. Bivariate and multivariate analyses are used for self-reported socio-demographic background, neighborhood walking behavior and perception, and objective measures of environments. RESULTS Environmental attributes positively associated with walking sufficiently to meet health recommendations included higher residential density and smaller street-blocks around home, and shorter distances to food and daily retail facilities from home. Threshold distances for eating/drinking establishments and grocery stores were 860 and 1445 feet. CONCLUSIONS Results questioned theoretical constructs of neighborhoods centered on recreation and educational uses. They pointed to finer mixes of uses than those characterizing suburban neighborhoods, and small spatial units of analysis and intervention to capture and promote neighborhood walkability.

Approaches to Measuring the Extent and Impact of Environmental Change in Three California Community-Level Obesity Prevention Initiatives

Despite growing support among public health researchers and practitioners for environmental approaches to obesity prevention, there is a lack of empirical evidence from intervention studies showing a favorable impact of either increased healthy food availability on healthy eating or changes in the built environment on physical activity. It is therefore critical that we carefully evaluate initiatives targeting the community environment to expand the evidence base for environmental interventions. We describe the approaches used to measure the extent and impact of environmental change in 3 community-level obesity-prevention initiatives in California. We focus on measuring changes in the community environment and assessing the impact of those changes on residents most directly exposed to the interventions.

What do injured workers think about their medical care and outcomes after work injury

Patient satisfaction is an important aspect of quality of care. Little information about injured workers’ satisfaction is available. A survey instrument was developed to assess “What Do Injured Workers Think About Their Medical Care?” Survey domains included access, satisfaction, reports of physician behaviors, and outcomes after work injury. Descriptive analyses were performed on more than 800 responses. Approximately 25% of respondents reported dissatisfaction with care. Satisfaction with choice of provider, interpersonal care, claims handling, and outcomes were major predictors of overall satisfaction. Spanish-speakers were more likely to be dissatisfied with physician communications. Months after injury, many workers reported significant pain and impact on job ability and daily function. Routine evaluation of patient satisfaction with occupational medical care could facilitate quality improvement efforts and informed purchaser and worker choice of occupational health services.

The Kaiser Permanente Community Health Initiative: Overview and Evaluation Design

We provide an overview of the Kaiser Permanente Community Health Initiative--created in 2003 to promote obesity-prevention policy and environmental change in communities served by Kaiser Permanente-and describe the design for evaluating the initiative. The Initiative focuses on 3 ethnically diverse northern California communities that range in size from 37,000 to 52,000 residents. The evaluation assesses impact by measuring intermediate outcomes and conducting pre- and posttracking of population-level measures of physical activity, nutrition, and overweight.

Evaluating the California Wellness Foundation’s Health Improvement Initiative: A Logic Model Approach

The difficulties of conducting randomized trials to evaluate community-based initiatives have led some researchers to argue in favor of a case study “logic model” approach to evaluation. This article describes a case study logic approach adopted for the evaluation of one community initiative, the Health Improvement Initiative (HII) funded by the California Wellness Foundation (TCWF). The HII is a comprehensive, community-based initiative designed to improve population health by implementing and sustaining community-level systems changes. Nine communities received funding to create broad-based community coalitions (Health Partnerships) that were charged with developing and implementing action plans around systems change. The HII is being evaluated using a case-study logic-model approach that uses quantitative and qualitative data to construct indicators of coalition functioning, systems changes, and population health. By examining the relationship between these indicators over time, it should be possible to determine if any changes in intermediate or long-term outcomes are associated with Health Partnership activities.

Kaiser Permanente's Community Health Initiative in Northern California: evaluation findings and lessons learned.

Purpose. To describe the evaluation findings and lessons learned from the Kaiser Permanente Healthy Eating Active Living–Community Health Initiative. Design. Mixed methods design: qualitative case studies combined with pre/post population-level food and physical activity measures, using matched comparison schools for youth surveys. Setting. Three low-income communities in Northern California (combined population 129,260). Subjects. All residents of the three communities. Intervention. Five-year grants of

Self-Management Support in a Web-Based Medical Record: A Pilot Randomized Controlled Trial

1.5 million awarded to each community to support the implementation of community- and organizational-level policy and environmental changes. Sectors targeted included schools, health care settings, worksites, and neighborhoods. Measures. Reach (percentage exposed) and strength (effect size) of the interventions combined with population-level measures of physical activity (e.g., minutes of physical activity) and nutrition (e.g., fruit and vegetable servings). Analysis. Pre/post analysis of population level measures, comparing changes in intervention to comparison for youth survey measures. Results. The population-level results were inconclusive overall, but showed positive and significant findings for four out of nine comparisons where “high-dose” (i.e., greater than 20% of the population reached and high strength) strategies were implemented, primarily physical activity interventions targeting school-age youth. Conclusion. The positive and significant changes for the high-dose strategies suggest that if environmental interventions are of sufficient reach and strength they may be able to favorably impact obesity-related behaviors.

Voluntary Public Health Insurance for Low-Income Families: The Decision to Enroll

Physicians were much less likely than other primary care team members to use a Web-based application to counsel patients with diabetes about behavior change.

US trends in receipt of appropriate diabetes clinical and self-care from 2001 to 2010 and racial/ethnic disparities in care.

A dominant issue in the health reform debate is whether insurance coverage should be voluntary or mandatory. Clearly, the factors that determine who will seek voluntary coverage are relevant to this policy issue. This article uses experience from Washington States Basic Health Plan to examine the enrollment choices of low-income families in a state-subsidized voluntary insurance plan offered through managed care organizations. We hypothesize that the decision to enroll, which encompasses the decisions to purchase insurance coverage and to select a particular plan, is influenced by four factors: the familys financial vulnerability, their risk perception, the price of coverage, and the transition costs of enrolling. Our enrollment model is supported by the data and has important implications for the design of voluntary programs. Families who choose to enroll are more likely to have a female head of household, young children, and a family member who has a part-time job and some college education. Higher premiums and availability of other insurance coverage decrease the probability of enrolling.

The L.E.A.D. framework: Using tools from evidence-based public health to address evidence needs for obesity prevention

Purpose The purpose of this study was to examine trends in the receipt of 8 recommended diabetes clinical and self-care indicators from 2001 to 2010 and assess racial/ethnic disparities in care. Methods This observational study examined receipt of A1C tests, annual eye and foot exams, flu vaccination, diabetes self-management education (DSME), exercise, self-monitoring of blood glucose (SMBG), and self feet examinations among US adults with diabetes using national survey data from 2001 to 2010. Analyses included estimating proportions for each indicator by year, testing differences in magnitude of change from 2001 to 2010 by race/ethnicity, and regression models to assess changes in care over time and factors associated with care. Results There were significant increases from 2001 to 2010 in A1C tests, annual foot exams, flu shots, DSME, and SMBG but declines in eye and self feet exams. DSME was positively associated with receipt of several care indicators. However, only half of respondents received DSME. White and black non-Hispanics, respectively, experienced improvements in at least 3 indicators. Hispanics experienced a significant increase in exercise but were consistently less likely than whites to receive or engage in most care. Conclusions While improvements in several indicators were observed, patterns varied by race/ethnicity, with Hispanics falling short on most measures. DSME was strongly associated with most care and demonstrates the potential to improve receipt of recommended care by increasing DSME participation. With the Affordable Care Act (ACA), health professionals have a prime opportunity to leverage ACA provisions to increase access to recommended services, including DSME.