***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: OBJECTIVE To improve health outcomes of children  , the US Maternal and Child Health Bureau has recommended more effective organization of preventive services within primary care practice s and more coordination between practice s and community-based agencies . However , applying these recommendations in communities is challenging because they require both more complex systems of care delivery within organizations and more complex interactions between them . To improve the way that preventive health care services are organized and delivered in 1 community , we design ed , implemented , and assessed the impact of a health care system-level approach , which involved addressing multiple care delivery processes , at multiple levels in the community , the practice , and the family . Our objective was to improve the processes of preventive services delivery to all children in a defined geographic community , with particular attention to health outcomes for low-income mothers and infants . DESIGN Observational intervention study in 1 North Carolina county ( population 182 000 ) involving low- income pregnant mothers and their infants , primary care practice s , and departments of health and mental health . An interrupted time-series design was used to assess rates of preventive services in office practice s before and after the intervention , and a historical cohort design was used to compare maternal and child health outcomes for women enrolled in an intensive home visiting program with women who sought prenatal care during the 9 months before the program 's initiation . Outcomes were assessed when the infants reached 12 months of age . INTERVENTIONS Our primary objective was to achieve changes in the process of care delivery at the level of the clinical interaction between care providers and patients that would lead to improved health and developmental outcomes for families . We selected interventions that were directed toward major risk factors ( eg , poverty , ineffective care systems for preventive care in office practice s ) and for which there was existing evidence of efficacy . The interventions involved community- , practice - , and family-level strategies to improve processes of care delivery  to families and children . The objectives of the community-level intervention were : 1 ) to achieve policy level changes that would result in changes in re sources available at the level of clinical care , 2 ) to engage multiple practice organizations in the intervention to achieve an effect on most , if not all , families in the community , and 3 ) to enhance communication between , among , and within public and private practice organizations to improve coordination and avoid duplication of services . The objective of the practice -level interventions was to overcome specific barriers in the process of care delivery so that preventive services could be effectively delivered . To assist the health department in implementing the family-level intervention , we provided assistance in hiring and training staff and ongoing consultation on staff supervision , including the use of structured protocol s for care delivery , and regular feedback data about implementation of the program . Interventions with primary care practice s focused on the design of the delivery system within the office and the use of teamwork and data in an " office systems " approach to improving clinical preventive care . All practice s ( N = 8) that enrolled at least 5 infants/month received help in assessing performance and developing systems ( eg , preventive services flow sheets ) for preventive services delivery . Family-level interventions addressed the process of care delivery to high-risk pregnant women ( < 100 % poverty ) and their infants . Mothers were recruited for the home visiting intervention when they first sought prenatal care at the community health center , the county 's largest provider of prenatal care to underserved women . The home visiting intervention involved teams of nurses and educators and involved 2 to 4 visits per month through the infant 's first year of life to provide parental education on fetal and infant health and development , enhance parents ' informal support systems , and link parents with needed health and human services . We included training in injury prevention and discipline , and home visitors assisted mothers in obtaining care from one of the primary care offices . RESULTS There were high levels of participation , changes in the organization of the delivery system , and improvements in preventive health outcomes . Agencies cooperated in joint contracting , staff training , and defining program eligibility . All 8 eligible practice s agreed to participate and 7/8 implemented at least 1 new office system element . Of eligible women , 89 % agreed to participate , and outcome data were available on 80 % ( 180/225 ) . After adjusting for differences in baseline characteristics , intervention group women were significantly more likely than comparison group women to use contraceptives ( 69 % vs 47 % ) , not smoke tobacco ( 27 % vs 54 % ) and have a safe and stimulating home environment for their children . Intervention group children were more likely to have had an appropriate number of well-child care visits ( 57 % vs 37 % ) and less likely to be injured ( 2 % vs 7 % ) . Intervention mothers also received Aid to Families with Dependent Children for fewer months after the birth of their child ( 7.7 months vs 11.3 months ) . CONCLUSIONS We observed a number of positive effects at all 3 levels of intervention . Policy-level changes at the state and community led to lasting changes in the organization and financing of care , which enabled changes in clinical services to take place . These changes have now been exp and ed beyond this community to other communities in the state . We were also able to engage multiple practice organizations , reduce duplication , and improve the coordination of care . Changes in the process of preventive services delivery were noted in participating practice s. Finally , the outcomes of the family-level intervention  were comparable in direction and magnitude to the outcomes of previous r and omized trials of the intervention . All the changes were achieved over a relatively brief 3-year study period , and many have been sustained since the project was completed . Tiered , interrelated interventions directed at an entire population of mothers and children hold promise to improve the effectiveness and outcomes of health care for families and children BACKGROUND Community Action Against Asthma ( CAAA ) is a community-based participatory research ( CBPR ) project that assesses the effects of outdoor and indoor air quality on exacerbation of asthma in children , and tests household- and neighborhood-level interventions to reduce exposure to environmental asthma triggers . Representatives of community-based organizations , academia , an integrated health system , and the local health department work in partnership on CAAA 's Steering Committee ( SC ) to design and implement the project . OBJECTIVE To conduct a process evaluation of the CAAA community-academic partnership . DESIGN In-depth interviews containing open-ended questions were conducted with SC members . Analysis included established methods for qualitative data , including focused coding and constant comparison methods . SETTING Community setting in Detroit , Michigan . PARTICIPANTS Twenty-three members of the CAAA SC . MEASUREMENTS Common themes identified by SC members relating to the partnership 's ability to achieve project goals and the successes and challenges facing the partnership itself . MAIN RESULTS Identified partnership accomplishments included : successful implementation of a complex project , identification of children with previously undiagnosed asthma , and diverse participation and community influence in SC decisions . Challenges included ensuring all partners ' influence in decision-making , the need to adjust to " a different way of doing things " in CBPR , constraints and costs of doing CBPR felt by all partners , ongoing need for communication and maintaining trust , and balancing the needs of science and the community through intervention . CONCLUSIONS CBPR can enhance and facilitate basic research , but care must be given to trust issues , governance issues , organizational culture , and costs of participation for all organizations involved In this paper we describe a successful multi-level participatory intervention grounded in principles of individual and group empowerment , and guided by social construction theory . The intervention addressed known and persistent inequities in influenza vaccination among African American and Latino older adults , and associated infections , hospitalizations and mortality . It was design ed to increase resident ability to make informed decisions about vaccination , and to build internal and external infrastructure to support sustainability over time . The intervention brought a group of social scientists , vaccine research ers , geriatricians , public health nurses , elder services providers and advocates together with senior housing management and activist African American and Latino residents living in public senior housing in a small east coast city . Two buildings of equal size and similar ethnic composition were r and omized as intervention and control buildings . Pre and post intervention surveys were conducted in both buildings , measuring knowledge , attitudes and peer norms . Processes and outcomes were documented at four levels : Influenza Strategic Alliance ( macro and exo levels ) , building management ( meso level ) , building resident committee ( meso level ) and individual residents . The Influenza Strategic Alliance ( I.S.A. ) provided ongoing re sources , information and vaccine ; the building management provided economic and other in-kind re sources and supported residents to continue flu clinics in the building . The V.I.P. Resident Committee conducted flu campaigns with flu clinics in English and Spanish . The vaccination rate in the intervention building at post test exceeded the study goal of 70 % and showed a significant improvement over the control building . The intervention achieved desired outcomes at all four levels and result ed in a significant increase in influenza vaccination , and improvements in pro-vaccination knowledge , beliefs , and underst and ing of health consequences Lay Health Promoters ( LHPs ) are widely used in community health education , but their use and evaluation in occupational health has been limited to farm workers . Evaluation data were collected from 30 r and omly selected Latino poultry processing workers who had an encounter with an LHP who delivered Maria 's Story , an occupational health lesson about cumulative trauma disorders ( CTDs ) . Participants had good recall of Maria 's Story . Most participants ( n = 18 , 60 % ) could identify the primary occupational health exposure linked to CTDs , more than 50 % of participants ( n = 16 ) could recall one or more ways of preventing CTDs , and 43.3 % ( n = 13 ) described in detail recommended treatments . Nearly one-half ( n = 12 ) reported an occupational health behavior change after hearing Maria 's Story . The results of this study suggest that LHPs may be effective in promoting occupational health and reducing occupational health disparities among ethnic minorities in high-risk occupations BACKGROUND The National Cancer Institute funded an 8-year , nonr and omized demonstration project for tobacco prevention and control , the American Stop Smoking Intervention Study ( ASSIST ) . To evaluate ASSIST , we compared changes in adult smoking prevalence , per capita cigarette consumption , and tobacco control policies between the 17 ASSIST states and the 33 non-ASSIST states and the District of Columbia . METHODS The strength of tobacco control index was used to measure state-level program elements directed at tobacco control , and the initial outcomes index ( IOI ) was used to measure states ' tobacco control policy outcomes . Prevalence data were obtained from the Tobacco Use Supplement to the Current Population Survey , and consumption data were obtained from the Tobacco Institute 's bimonthly sales figures for cigarette packs moved from wholesale warehouses . Two-stage regression and mixed-effects linear modeling were used to analyze the various outcomes . Statistical analyses for testing individual regression coefficients were one-sided . RESULTS ASSIST states had a greater decrease in adult smoking prevalence than non-ASSIST states , with an adjusted difference of -0.63 % ( P = .049 ) . Per capita cigarette consumption was not statistically significantly different between ASSIST and non-ASSIST states . However , an increase in the IOI of a state from the 25th to the 75th percentile was associated with a reduction in per capita cigarette consumption by 0.57 packs per person per month . State IOI was also inversely , albeit not statistically significantly , associated with smoking prevalence ( regression coefficient = -0.11;P = .06 ) . CONCLUSIONS The reduction in adult smoking prevalence associated with ASSIST could have translated into approximately 278 700 fewer smokers nationwide if all states had implemented ASSIST . Investment in building state-level tobacco control capacity and promoting changes in tobacco control policies are effective strategies for reducing tobacco use Objective : To evaluate changes in the worksite environment in response to a multilevel intervention over a 2-year period . Methods : Worksites were recruited in the greater Seattle area , and 34 were r and omized to intervention or comparison condition . The intervention was based on the ecological model , with a framework of defined phases of intervention that included worksite-wide events implemented in partnership with employee-based advisory boards . The assessment of the worksite environment used a modification of the Checklist of Health Promotion Environments at Worksites . Subscales were developed using baseline data only . The intervention effect on different aspects of the worksite environment was estimated using logistic regression with robust estimating procedures . Results : Only changes in the physical activity and nutrition information environments were significantly associated with the intervention . Conclusions : This article provides one of the first attempts at using environmental assessment in the evaluation of worksite interventions OBJECTIVES The North Carolina WISEWOMAN project was initiated to evaluate the feasibility of exp and ing an existing cancer screening program to include a cardiovascular disease ( CVD ) screening and intervention program among low-income women . METHODS Seventeen North Carolina county health departments were design ated as minimum intervention ( MI ) , and 14 as enhanced intervention ( EI ) . The EI included three specially constructed counseling sessions spanning 6 months using a structured assessment and intervention program tailored to lower income women . RESULTS Of the 2,148 women screened , 40 % had elevated total cholesterol ( > or = 240 mg/dL ) , 39 % had low high-density lipoprotein cholesterol ( HDL-C ) levels ( < 45 mg/dL ) , and 63 % were hypertensive ( systolic blood pressure 140 and /or diastolic blood pressure > or = 90 mm Hg or on hypertensive medication ) . The majority of women ( 86 % ) had at least one of these three risk factors . Seventy-six percent were either overweight or obese . After 6 months of follow-up in the EI health departments , changes in total cholesterol levels , HDL-C levels , diastolic blood pressure , and BMI were observed ( -5.8 mg/dL , -0.9 mg/dL , -1.7 mm Hg , and -0.3 kg 
    Output:
    
The findings from this descriptive review suggest that multilevel interventions have positive effects on several health behavior outcomes , including cancer prevention and screening , as well improving the quality of health-care system processes .