Dean Schillinger

• University of California, San Francisco

Background Social norms can influence individual health behaviors. Shifts in social norms for smoking were critical for the effectiveness of tobacco control efforts such as excise taxes. Sugar-sweetened beverage (SSB) excise taxes have been implemented in municipalities across the United States to reduce SSB intake and improve health. We sought to...

Cost-effectiveness analyses are commonly used to inform health care and public health policy decisions. However, standard approaches may systematically disadvantage marginalized groups by incorporating assumptions of persisting health inequities. We examined how competing risks, baseline health care costs, and indirect costs can differentially affe...

To show how sugar-sweetened beverage (SSB) taxes were framed in posts on Twitter (now known as X) through text and images, we conducted a content analysis on a sample of Tweets from California users posted between January 1, 2015 and December 31, 2018 about SSB taxes in Berkeley, San Francisco, Oakland, and/or Albany, California. We evaluated posts...

Objective:Workplace sugar-sweetened beverage (SSB) sales bans can reduce SSB consumption. Because stress and anxiety can promote sugar consumption, we examined whether anxiety among hospital employees during the COVID-19 pandemic was associated with changes in SSB consumption and explored whether this relationship varied by exposure to a workplace...

Objective Over 90 clinical trials demonstrate the efficacy of the collaborative care model (CoCM) to treat depression in primary care but there is significant variability in real‐world CoCM implementation and scalability. This study aimed to determine the feasibility and effectiveness of an adapted CoCM in a safety‐net primary care setting. Method...

Importance Sugar-sweetened beverage (SSB) taxes are promoted as key policies to reduce cardiometabolic diseases and other conditions, but comprehensive analyses of SSB taxes in the US have been difficult because of the absence of sufficiently large data samples and methods limitations. Objective To estimate changes in SSB prices and purchases foll...

Importance Telehealth implementation associated with the COVID-19 public health emergency (PHE) affected patient–clinical team interactions in numerous ways. Yet, studies have narrowly examined billed patient-clinician visits rather than including visits with other team members (eg, pharmacists) or between-visit interactions. Objective To evaluate...

Sugar-sweetened beverages (SSB) contribute to illness, especially among marginalized communities and children targeted by the beverage industry. SSB taxes can reduce consumption, illness burden, and health inequities, while generating revenue for health programs, and as one way to hold the industry responsible for their harmful products and marketi...

Introduction We carried out a two-phase, qualitative evaluation of a novel public health campaign to promote COVID-19 vaccination among youth and young adults of color (YOC), called Survival Pending Revolution. The campaign, commissioned by California's Department of Public Health, was created by YOC spoken word artists, under the direction of the...

Background While a 2021 federal commission recommended that the United States government levy a sugar-sweetened beverage (SSB) tax to improve diabetes prevention and control efforts, evidence is limited regarding the longer-term impacts of SSB taxes on SSB purchases, health outcomes, costs, and cost-effectiveness. This study estimates the impact an...

Modern communication between health care professionals and patients increasingly relies upon secure messages (SMs) exchanged through an electronic patient portal. Despite the convenience of secure messaging, challenges include gaps between physician and patient expertise along with the asynchronous nature of such communication. Importantly, less re...

Background: Latinos suffer from health disparities associated with excessive consumption of sugar-sweetened beverages. This study aimed to test the effectiveness of messaging using critical health communication approaches and delivered by two narrative modalities (video and comic book) with similar content that aims to empower Latinos to advocate f...

Background While over 90 clinical trials demonstrate the efficacy of the collaborative care model (CCM) to treat depression in primary care, there is significant variability in real-world CCM implementation and scalability. Our objective was to determine the feasibility and effectiveness of an adapted CCM in a safety-net primary care setting. Meth...

Abstract Background Individuals with serious mental illness often do not receive guideline-concordant metabolic screening and human immunodeficiency virus (HIV) testing, contributing to increased morbidity and premature mortality. This study evaluates the effectiveness of CRANIUM (Cardiometabolic Risk Assessment and treatment through a Novel Integr...

The COVID-19 pandemic, coupled with the domestic socio-political unrest of 2020, provides a critical opportunity to reframe how we engage with youth around health and disease risk. The Bigger Picture (TBP), a spoken word, arts-based public health literacy campaign, uses a social justice and racial equity frame to activate youth around social determ...

Background Inequitable follow-up of abnormal cancer screening tests may contribute to racial/ethnic disparities in colon and breast cancer outcomes. However, few multi-site studies have examined follow-up of abnormal cancer screening tests and it is unknown if racial/ethnic disparities exist. Objective This report describes patterns of performance...

Introduction: The COVID-19 pandemic has altered access to health care; it remains unclear how patients with chronic illness and disability and their family caregivers are adapting to these changes. In this study, we examined changes in family caregiver roles helping care recipients with chronic illness and disability navigate health care needs duri...

Some reports suggest that the COVID-19 pandemic resulted in shifts to unhealthier diets. These unhealthier diets may include sugar-sweetened beverages (SSBs), which strongly contribute to diabetes and other chronic diseases. Using cross-sectional surveys in the San Francisco Bay Area, California, USA we sought to assess self-reported SSB consumptio...

The strategic use of media is a common approach to promote health. A large body of evidence identifies specific features that increase message efficacy, including tailoring messages to the target audience and using a storytelling format. Yet most message testing research has focused on individual-level outcomes, ignoring the social and environmenta...

Little quantitative research has explored which clinician skills and behaviors facilitate communication. Mutual understanding is especially challenging when patients have limited health literacy (HL). Two strategies hypothesized to improve communication include matching the complexity of language to patients’ HL (“universal tailoring”); or always u...

Traditional health education efforts rarely align with youth social justice values. The Bigger Picture (TBP), a spoken word arts campaign, leverages a social justice approach to activate youth around the social determinants of type 2 diabetes (T2D). This quasi-experimental study examines the impact of embedding TBP in urban, low-income high schools...

Objective To explore physician leaders’ perspectives on processes and priorities for engaging with caregivers in their clinical practices as well as within their safety net health systems. Methods We conducted in-depth semi-structured interviews with primary care physicians in care management leadership at three California safety net health system...

Background Individuals with serious mental illness often do not receive guideline-concordant metabolic screening and human immunodeficiency virus (HIV) testing, contributing to increased morbidity and premature mortality. This study evaluates the effectiveness of CRANIUM (Cardiometabolic Risk Assessment and treatment through a Novel Integration mod...

Background Traditional health education efforts rarely align with youth social justice values. The Bigger Picture (TBP), a public health literacy campaign that uses spoken word art to promote health, leverages a social justice approach to activate youth around the social determinants of type 2 diabetes (T2D). Objective We examine the impact of TBP...

This article synthesizes what is known about the relationship between social disadvantage and measures of health literacy (HL), and reviews the research examining whether low HL is an explanatory factor connecting social disadvantage, health outcomes, and health disparities. Written from a United States perspective, this article offers a novel conc...

To assess whether primary care medical homes (PCMHs) are accurately identified for patients receiving care in a specialty mental health clinic within an integrated public delivery system. This study reviewed the electronic records of patients in a large urban mental health clinic. The study defined ‘matching PCMH’ if the same primary care clinic wa...

Background Efforts to confront the type 2 diabetes (T2D) epidemic have been stymied by an absence of effective communication on policy fronts. Whether art can be harnessed to reframe the T2D discourse from an individual, biomedical problem to a multilevel, communal and social problem is not known. Method We explored whether spoken word workshops e...

Self-management education (SME) is a key determinant of diabetes treatment outcomes. While SME programs are often adapted for implementation, the impact of adaptations on diabetes SME effectiveness is not well documented. This study evaluated the impact of the implementation fidelity of diabetes SME programs on program effectiveness, exploring whic...

Importance Fruit and vegetable vouchers have been implemented by cities and counties across the US to increase fruit and vegetable intake and thereby improve overall nutritional quality. Objective To determine whether and why use of fruit and vegetable vouchers are associated with varied nutritional intake across different populations and environm...

Objective In the National Library of Medicine funded ECLIPPSE Project (Employing Computational Linguistics to Improve Patient-Provider Secure Emails exchange), we attempted to create novel, valid, and scalable measures of both patients’ health literacy (HL) and physicians’ linguistic complexity by employing natural language processing (NLP) techniq...

The substantial expansion of secure messaging (SM) via the patient portal in the last decade suggests that it is becoming a standard of care, but few have examined SM use longitudinally. We examined SM patterns among a diverse cohort of patients with diabetes (N = 19 921) and the providers they exchanged messages with within a large, integrated hea...

Over the past 2 decades, there has been increasing recognition of the importance of health literacy (HL) with respect to health outcomes. This has been paired with investments in HL-related research from the National Institutes for Health (NIH) (Kindig et al., 2004), particularly since the publication of the 2004 National Academy Report on HL (Inst...

Introduction Smoking is a significant modifiable risk factor for mortality for persons with serious mental illness (SMI), who have a life expectancy 15–20 years shorter than the general population. Individuals with SMI and comorbid diabetes who are smokers face an even higher risk of cardiovascular complications and early death. Yet despite high ra...

Background: Low literacy skills impact important aspects of communication, including health-related information exchanges. Unsuccessful communication on the part of physician or patient contributes to lower quality of care, is associated with poorer chronic disease control, jeopardizes patient safety and can lead to unfavorable healthcare utilizati...

Objective: To develop novel, scalable, and valid literacy profiles for identifying limited health literacy patients by harnessing natural language processing. Data source: With respect to the linguistic content, we analyzed 283 216 secure messages sent by 6941 diabetes patients to physicians within an integrated system's electronic portal. Socio...

Objective To effectively confront the type 2 diabetes (T2D) epidemic, policymakers and the public need to problematize T2D less as a medical and more as a social problem. An award-winning T2D prevention campaign was harnessed to determine the most successful ways of framing ads on Facebook. Hypothesis We will observe variation in the effectiveness...

Sugar-sweetened beverages (SSBs) increase chronic disease risk. We estimated the impact on employee health and health care spending of banning SSB sales in California-based health care organizations. We used survey data from a large, multisite health care organization in California, sampling 2,276 employees three months before and twelve months aft...

Introduction Type 2 diabetes (T2D) is a global epidemic, and nations are struggling to implement effective healthcare strategies to reduce the burden. While efficacy studies demonstrate that metformin can reduce incident T2D by half among younger, obese adults with prediabetes, its real-world effectiveness are understudied, and its use for T2D prev...

Objectives: Safety-net health care systems, serving vulnerable populations, see longer delays to timely colonoscopy after a positive fecal occult blood test (FOBT), which may contribute to existing disparities. We sought to identify root causes of colonoscopy delay after positive FOBT result in the primary care safety net. Methods: We conducted...

Purpose: To explore the experiences of living with painful diabetic neuropathy (PDN) and with a group acupuncture intervention in a sample of low-income, diverse patients. Methods: We conducted a randomized clinical trial of a 12-week group acupuncture intervention for PDN. Data included validated measures of patient-reported outcomes, including pa...

Patients with diabetes and limited health literacy (HL) may have suboptimal communication exchange with their health care providers and be at elevated risk of adverse health outcomes. These difficulties are generally attributed to patients’ reduced ability to both communicate and understand health-related ideas as well as physicians’ lack of skill...

Background. Patient comprehension is fundamental to valid informed consent. Current practices often result in inadequate patient comprehension. Purpose. An updated review to evaluate the characteristics and outcomes of interventions to improve patient comprehension in clinical informed consent. Data Sources. Systematic searches of MEDLINE and EMBAS...

Background Diabetes prevalence is twice as high among people with severe mental illness (SMI) when compared to the general population. Despite high prevalence, care outcomes are not well understood. Objective To compare diabetes health outcomes received by people with and without comorbid SMI, and to understand demographic factors associated with...

A safety net system's trauma-informed approach to integrating interpersonal violence into behavioral health programs in primary care.

Background Little is known about patients who have caregiver proxies communicate with healthcare providers via portal secure messaging (SM). Since proxy portal use is often informal (e.g., sharing patient accounts), novel methods are needed to estimate the prevalence of proxy-authored SMs. Objective (1) Develop an algorithm to identify proxy-autho...

Rationale & Objective Sustainable interventions that enhance chronic kidney disease (CKD) management are not often studied in safety-net primary care, in which populations bear a disproportionate burden of disease and experience translational gaps between research and practice. We tested the feasibility of implementing and the impact of 2 technolog...

Objective: Existing pharmacologic approaches for painful diabetic neuropathy (PDN) are limited in efficacy and have side effects. We examined the feasibility, acceptability, and effects of group acupuncture for PDN. Design and setting: We randomized patients with PDN from a public safety net hospital to 1) usual care, 2) usual care plus 12 weeks...

Objective: Although people with severe mental illness (SMI) have high rates of diabetes and other metabolic disorders, adherence to recommended screening guidelines is low. This study aimed to compare primary care clinicians' and psychiatrists' attitudes toward metabolic monitoring and treatment of patients with SMI. Methods: Primary care clinic...

Background: Patient portals are becoming ubiquitous. Previous research has documented substantial barriers, especially among vulnerable patient subgroups such as those with lower socioeconomic status or limited health literacy (LHL). We tested the effectiveness of delivering online, video-based portal training to patients in a safety net setting....

Limited health literacy is a barrier to optimal healthcare delivery and outcomes. Current measures requiring patients to self-report limitations are time-consuming and may be considered intrusive by some. This makes widespread classification of patient health literacy challenging. The objective of this study was to develop and validate “literacy pr...

Survey questions coding and definitions. (PDF)

Given the prevalence of medication nonadherence (Sabaté, 2003), clinicians and public health researchers are compelled to design, implement, evaluate, and iterate strategies to improve fidelity to medication regimens. Although barriers to medication adherence range from the individual to the structural, addressing the ambiguity, technicality, and v...

Background: Team-based care is an innovative approach to primary care in which groups of health care professionals work collaboratively to manage care for groups of patients. Safety-net organizations face specific barriers to implementing health care innovations. More research is needed that documents the dynamics that inform implementation and su...

Patient safety in ambulatory care has not been routinely measured. California implemented a pay-for-performance program in safety-net hospitals that incentivized measurement and improvement in key areas of ambulatory safety: referral completion, medication safety, and test follow-up. We present two years of program data (collected during July 2015-...

Importance Advance care planning improves the receipt of medical care aligned with patients’ values; however, it remains suboptimal among diverse patient populations. To mitigate literacy, cultural, and language barriers to advance care planning, easy-to-read advance directives and a patient-directed, online advance care planning program called PRE...

Little is known about dissemination and implementation in safety net settings. The authors conducted a literature review of innovation/implementation studies in US safety net health care settings between 2008 and 2017. Each article was coded for (1) intervention characteristics, (2) implementation stage, (3) internal versus external ownership, and...

Objectives: Language barriers in healthcare are associated with worse glycemic control among Latino patients with limited English proficiency and diabetes. We examined the association of patient-physician language concordance with lipid (low-density lipoprotein cholesterol [LDL-C]) and systolic blood pressure (SBP) control. Study design: Retrosp...

Ultimately, the goal of the field of health literacy and the purpose of HLRP: Health Literacy Research and Practice is empowerment—to help people gain more control over their health. Studies reported in HLRP: Health Literacy Research and Practice will vary, but our continuing objective is to improve individuals' and the public's health by dissemina...

Context: Prediabetes is prevalent and significantly increases lifetime risk of progression to type 2 diabetes. This review summarizes the evidence surrounding metformin use for type 2 diabetes prevention. Evidence acquisition: Articles published between 1998 and 2017 examining metformin use for the primary indication of diabetes prevention avail...

Nonadherence to medication regimens is common, with approximately 50% of patients not taking their medications as prescribed. The Universal Medication Schedule (UMS) is a set of standardized, evidence-based, and patient-centered instructions for pill-form medications that has demonstrated improvements in adherence by promoting patient comprehension...

Background Clinical performance measures, such as for cholesterol control targets, have played an integral role in assessing the value of care and translating evidence into clinical practice. New guidelines often require development of corresponding performance metrics and systems changes that can be especially challenging in safety-net health care...

Purpose: An initiative to implement patient-centered medication labeling at 4 pharmacies within a publicly funded safety-net healthcare system is described. Summary: Medication nonadherence negatively affects patient outcomes and safety. Nonadherence has been attributed to poor understanding of instructions on medication labels. Research has dem...

Methods: We examined whether and how TBP PSAs advance health literacy among low-income, minority youth. We showed nine PSAs, asking individuals open-ended questions via questionnaire, then facilitating a focus group to reflect upon the PSAs. Results: Questionnaire responses revealed a balance between individual vs. public health literacy. Some f...

Background Diabetes self-management education (DSME) is considered essential for improving the prevention and care of diabetes through empowering patients to increase agency in their own health and care processes. However, existing evidence regarding DSME in the EU Member States (EU MS) is insufficient to develop an EU-wide strategy. Objectives Th...

Abstract Background Clinicians have difficulty accurately assessing medication non-adherence within chronic disease care settings. Health information technology (HIT) could offer novel tools to assess medication adherence in diverse populations outside of usual health care settings. In a multilingual urban safety net population, we examined the val...

Background: Many individuals with chronic kidney disease (CKD) do not receive guideline-concordant care. We examined the impact of a team-based primary care CKD registry on clinical measures and processes of care among patients with CKD cared for in a public safety-net health care delivery system. Study design: Pragmatic trial of a CKD registry...

Though eating with others is often a social behavior, relationships between social contexts of eating and nutrient intake have been underexplored. This study evaluates how social aspects of eating - frequencies of eating meals with others, meals prepared at home, and meals outside the home - are associated with nutrient intake. Because diet improve...

Background: Safety net health systems face barriers to effective ambulatory medication reconciliation for vulnerable populations. Although some electronic health record (EHR) systems offer safety advantages, EHR use may affect the quality of patient-provider communication. Objective: This mixed-methods observational study aimed to develop a conc...

p>Background: Diabetes self-management education (DSME) is generally considered to be a key determinant of the treatment outcomes and related costs of diabetes mellitus. While DSME programmes generally have positive outcomes, their effects may depend on certain factors, such as the type of programmes provided and patients’ level of health literacy...

We sought to understand stakeholder perspectives on barriers to metabolic screening for people with severe mental illness. We additionally assessed the feasibility of expanding psychiatrists’ scope of practice to include treatment of cardiometabolic abnormalities. We conducted four focus groups among patients with severe mental illness, community p...

Background Individuals with severe mental illness (e.g., schizophrenia, bipolar disorder) die 10–25 years earlier than the general population, primarily from premature cardiovascular disease (CVD). Contributing factors are complex, but include systemic-related factors of poorly integrated primary care and mental health services. Although evidence-b...

Background: Severe mental illness (SMI) is associated with increased risk for type 2 diabetes, partly due to adverse metabolic effects of antipsychotic medications. In public health care settings, annual screening rates are 30%. We measured adherence to national diabetes screening guidelines for patients taking antipsychotic medications. Objectiv...

Objective: This study examined mammogram screening rates among women with severe mental illness by using a socioecological framework. Because it has been shown that people with severe mental illness receive less preventive health care overall, the analysis included psychosocial predictors of mammogram screening rates in a cohort of women with seve...

Adolescence and young adulthood, a period essential for determining exposures over the life-course, is an ideal time to intervene to lower cancer risk. This demographic group can be viewed as both the target audience and generator of messages for cancer prevention, such as skin cancer, obesity-, tobacco-, and human papillomavirus−related cancers. T...

People with serious mental illness, such as schizophrenia and bipolar disorder, experience premature mortality, often from cardiovascular disease (CVD). Unfortunately, people with serious mental illness typically are not screened or treated for CVD risk factors despite national guideline recommendations. Access to primary preventive care in communi...

Purpose: To describe use of complementary health approaches (CHAs) among patients with type 2 diabetes, and independent associations between CHA use and Hemoglobin A1c (A1C) and lower-density lipoprotein (LDL) cholesterol. Methods: Participants were enrolled onto the SMARTSteps Program, a diabetes self-management support program conducted betwee...

Largely driven by the financial incentives of the HITECH Act’s Meaningful Use program as part of federal US health care reform, access to portal Web sites has rapidly expanded, allowing many patients to view their medical record information online. Despite this expansion, there is little attention paid to the accessibility of portals for more vulne...

Background: Low functional health literacy (HL) has been associated with poor self-management of chronic conditions, including type 2 diabetes mellitus (T2DM), an inefficient use of health services, and higher health care costs. Low functional HL and limited English language proficiency both independently predict poor glycemic control among Latino...

Electronic health record (EHR) implementation may affect time allocation during patient visits.¹ Clinicians may use EHRs in silence, risking lower patient satisfaction,² or by multitasking while talking with patients. Concurrent multitasking (performing ≥2 tasks simultaneously) is associated with increased error risk and time to complete tasks.³ We...

Health policies encourage implementing quality measurement with performance targets. The 2010-2015 California Medicaid waiver mandated quality measurement and reporting. In 2013, California safety net hospitals participating in the waiver set a voluntary performance target (the 90th percentile for Medicare preferred provider organization plans) for...

Objective: This study assessed differences in diabetes prevalence based on race-ethnicity among people with severe mental illnesses. Methods: This retrospective cohort study examined diabetes prevalence in 2009 among California Medicaid enrollees with severe mental illness who were screened for diabetes (N=19,364). Poisson regression assessed di...

Objective: This study aimed to determine cervical cancer screening rates among women with severe mental illness. Methods: California Medicaid administrative records (2010-2011) for 31,308 women with severe mental illness were examined. Participants received specialty mental health services and were not dually eligible for Medicare. Poisson model...

Associations between neighborhood food environment and adult body mass index (BMI; weight (kg)/height (m)2) derived using cross-sectional or longitudinal random-effects models may be biased due to unmeasured confounding and measurement and methodological limitations. In this study, we assessed the within-individual association between change in foo...

Objective Among adults with diabetes, depression is associated with poorer adherence to cardiometabolic medications in ongoing users; however, it is unknown whether this extends to early adherence among patients newly prescribed these medications. This study examined whether depressive symptoms among adults with diabetes newly prescribed cardiometa...

Objective: US health care institutions are implementing secure websites (patient portals) to achieve federal Meaningful Use (MU) certification. We sought to understand efforts to implement portals in "safety net" health care systems that provide services for low-income populations. Materials and methods: Our rapid ethnography involved visits at...

Objective: Although primary care is associated with better outcomes, many individuals with serious mental illness do not receive general medical services. This study examined patient-level factors associated with not having outpatient general medical visits among individuals with serious mental illness in California. Methods: The study analyzed...

The housing foreclosure crisis was harmful to the financial well-being of many households. In the present study, we investigated the health effects of the housing foreclosure crisis on glycemic control within a population of patients with diabetes. We hypothesized that an increase in the neighborhood foreclosure rate could worsen glycemic control b...