Information on individual-level health behaviors came from the 2015 Behavioral Risk Factor Surveillance Survey (BRFSS) SMART dataset. The 2015 BRFSS SMART dataset is a sub-sample of the 2015 state BRFSS surveys based on geographies defined as metropolitan statistical areas, micropolitan statistical areas, and metropolitan divisions (collectively called MMSAs) made publicly available to researchers. The 2015 BRFSS Smart dataset included 132 MMSAs where at least 500 BRFSS surveys were collected [18].

Individual health behaviors selected for this study were those identified by the Centers for Disease Control and Prevention (CDC) as “Winnable Battles”. Winnable Battles are health outcomes for which the CDC believes that public health can make significant progress in a relatively short time frame (i.e., within one to 4 years), have a large-scale public impact, and have evidenced-based interventions readily available for ease of implementation. From the “Winnable Battles” list, we included the following modifiable behaviors/conditions into our analysis: smoking, wearing a seatbelt, binge drinking, eating vegetables daily, eating fruit daily, general exercise in a month, vigorous exercise (300 min) in a week and being overweight or obese (based on self-reported height and weight). Additionally, while not designated by the CDC as a “Winnable Battle”, flu vaccinations are also an important measure of community health where LHDs and nonprofit hospitals may collaborate and was thus included in our analysis. While we did not have access to specific collaborative action strategies, many of the included measures are commonly identified in community health needs assessments (CHNAs) as being health needs in the community (healthy eating, physical activity, smoking, etc.) [19, 20].

In addition to studying the impact of LHD-hospital collaboration on specific individual health behaviors, we also conducted analyses using two index measures of the health behaviors. We created one index for risky behaviors and another for healthy lifestyle behaviors (healthy eating and exercise).

The risky behaviors index included wearing a seatbelt, not smoking, not binge drinking and getting a flu shot. For each individual respondent, we assigned a score for this index based on the number of specific behaviors that the individual reported undertaking (or in the case of smoking and binge drinking reported not undertaking). Thus, if an individual did not report undertaking any of these behaviors, we assigned a score of zero. If an individual reported all of the behaviors, we assigned a score of four. To create the healthy lifestyle index, we combined the specific behaviors of eating vegetable(s) daily, eating fruit daily and vigorously exercising. We found a high correlation between general exercise and vigorous exercise and felt the latter was more representative of a healthy lifestyle, so we included that variable only. For this index, we also assigned a score to each individual respondent based on the number of behaviors that reportedly were undertaken. Thus, the healthy lifestyle index ranged from zero (if an individual did not report any of the variables) to three (if an individual reported eating fruit, vegetables and vigorously exercising). Index variables were analyzed as continuous outcomes.

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