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Much research focuses on producing maximal intervention effects. This has generally not resulted in interventions being rapidly or widely adopted or seen as feasible given resources, time, and expertise constraints in the majority of real-world settings. We present a definition and key characteristics of a minimum intervention needed to produce change (MINC). To illustrate use of a MINC condition, we describe a computer-assisted, interactive minimal intervention, titled Healthy Habits, used in three different controlled studies and its effects. This minimal intervention produced modest to sizable health behavior and psychosocial improvements, depending on the intensity of personal contacts, producing larger effects at longer-term assessments. MINC comparison conditions could help to advance both health care and health research, especially comparative effectiveness research. Policy and funding implications of requiring an intervention to be demonstrated more effective than a simpler, less costly MINC alternative are discussed.

Coronary heart disease is a pervasive public health problem with a heavy burden among older women. There is a need for developing effective interventions for addressing this problem and for evaluating the dissemination potential of such interventions. A multiple-behavior-change program originally designed for men with heart disease was adapted for women at high risk of heart disease in two randomized clinical trials-the Mediterranean Lifestyle Program and ¡Viva Bien!. Results from these two trials, including readiness for dissemination, are evaluated using the RE-AIM framework in terms of Reach, Effectiveness, Adoption, Implementation, and Maintenance. Program adaptations produced relative high reach as well as consistent and replicated effectiveness and maintenance, and were adopted by a high percentage of primary care offices and clinicians approached. We discuss key findings, lessons learned, future directions for related research, and use of RE-AIM for program development, adaptation, scale-up, and evaluation.

Information on cost-effectiveness of multiple-risk-factor lifestyle interventions for Latinas with diabetes is lacking. The aim of this paper is to evaluate costs and cost-effectiveness for ¡Viva Bien!, a randomized trial targeting Latinas with type 2 diabetes. We estimated 6-month costs; calculated incremental costs per behavioral, biologic, and quality-of-life change; and performed sensitivity analyses from health plan and participant perspectives. Recruitment, intervention, and participant costs were estimated at $45,896, $432,433, and $179,697, respectively. This translates to $4,634 in intervention costs per ¡Viva Bien! participant; $7,723 in both per unit reduction in hemoglobin A1c and per unit reduction in body mass index. Although costs may be higher than interventions that address one risk factor, potential risks for longer-term health-care costs are high for this at-risk group. Given the benefits of ¡Viva Bien!, cost reductions are recommended to enhance its efficiency, adoption, and long-term maintenance without diluting its effectiveness.

Latinas with type 2 diabetes are in need of culturally sensitive interventions to make recommended longterm lifestyle changes and reduce heart disease risk. To test the longer-term (24-month) effects of a previously successful, culturally adapted, multiple-healthbehavior- change program, ¡Viva Bien!, 280 Latinas were randomly assigned to usual care or ¡Viva Bien!. Treatment included group meetings to promote a culturally adapted Mediterranean diet, physical activity, supportive resources, problem solving, stress-management practices, and smoking cessation. ¡Viva Bien! participants achieved and maintained some lifestyle improvements from baseline through 24 months, including significant improvements for psychosocial outcomes, fat intake, social-environmental support, body mass index, and hemoglobin A1c. Effects tended to diminish over time. The ¡Viva Bien! multiple-behavior program was effective in improving and maintaining some psychosocial, behavioral, and biological outcomes related to heart health across 24 months for Latinas with type 2 diabetes, a high-risk, underserved population (ClinicalTrials.gov number, NCT00233259).

Background: Culturally appropriate interventions are needed to assist Latinas in making multiple healthful lifestyle changes., Purpose: The purpose of this study was to test a cultural adaptation of a successful multiple health behavior change program, ¡Viva Bien!, Methods: Random assignment of 280 Latinas with type 2 diabetes to usual care only or to usual care + ¡Viva Bien!, which included group meetings for building skills to promote the Mediterranean diet, physical activity, stress management, supportive resources, and smoking cessation., Results: ¡Viva Bien! participants compared to usual care significantly improved psychosocial and behavioral outcomes (fat intake, stress management practice, physical activity, and social-environmental support) at 6 months, and some improvements were maintained at 12 months. Biological improvements included hemoglobin A1c and heart disease risk factors., Conclusions: The ¡Viva Bien! multiple lifestyle behavior program was effective in improving psychosocial, behavioral, and biological/quality of life outcomes related to heart health for Latinas with type 2 diabetes.

Computer-tailored behavior change programs offer the potential for reaching large populations at a much lower cost than individual or group-based programs. However, few of these programs to date appear to integrate behavioral theory with user choice, or combine different electronic modalities. We describe the development of an integrated CD-ROM and interactive voice response dietary change intervention that combines behavioral problem-solving theory with a high degree of user choice. The program, WISE CHOICES, is being evaluated as part of an ongoing trial. This paper describes the program development, emphasizing how user preferences are accommodated, and presents implementation and user satisfaction data. The program was successfully implemented; the linkages among the central database, the CD-ROM and the automated telephone components were robust, and participants liked the program almost as well as a counselor-delivered dietary change condition. Multi-modality programs that emphasize the strengths of each approach appear to be feasible. Future research is needed to determine the program impact and cost-effectiveness compared with counselor-delivered intervention.

Background: Physical activity (PA) is important for management of diabetes, yet practical interventions that achieve sustained behavior change are rare., Purpose: The goals of this research were to evaluate the effectiveness of a multifaceted PA intervention for people with type 2 diabetes that emphasized participant choice in activity selection. Baseline activity patterns were examined to determine whether they predicted changes in PA at 2 months., Methods: Three hundred thirty-five participants were recruited from 42 primary care physicians and then randomized to either a computer-assisted, tailored self-management intervention (N = 174) or health risk appraisal with feedback control (N = 161). Primary outcome measures included the Community Healthy Activities Model Program for Seniors Questionnaire, diet, and psychosocial assessments at baseline and 2 months., Results: For 301 participants who completed the 2-month follow-up, the intervention significantly improved all PA (p < .01) and moderate PA (metabolic equivalents > 3.0, p < 01) relative to controls. Baseline cluster analyses grouped participant activity patterns into three categories. At 2 months, cluster assignment differentially predicted change in calories expended in moderate, rote, sport, and lifestyle PA., Conclusions: A computer-assisted, multifaceted approach to PA demonstrated improvement after 2 months. The results suggest that individuals are capable of adjusting their activity patterns to maximize their PA.

There is great interest in, but few instruments to assess, multiple levels of support and community resources from a social-ecological perspective. This study evaluated the psychometric characteristics of the Chronic Illness Resources Survey (CIRS) and its sensitivity to a multifaceted social-ecological intervention to enhance personally relevant community resources supportive of healthful lifestyles. Participants were 293 post-menopausal women having type 2 diabetes who were part of a multiple-behavior lifestyle change program. Key measures included the CIRS, a validated Food Frequency Questionnaire, the Kristal Fat and Fiber Behavior Questionnaire, the CHAMPS Activities Questionnaire for Older Adults, and other measures of social support. Results revealed that the CIRS displayed good psychometric characteristics in this new sample, was significantly correlated as predicted with established measures of social support, was sensitive to intervention, and partially mediated the effects of intervention on both dietary and physical activity outcomes. The 22-item CIRS scale appears useful for assessing multilevel support resources, predicting successful behavior change and detecting social-ecological intervention effects.

Background: The Mediterranean Lifestyle Program was evaluated for its effects on multiple behavioral risk factors for coronary heart disease (CHD) among postmenopausal women with diabetes., Purpose: Our purpose is to test a comprehensive lifestyle management intervention to reduce CHD risk in postmenopausal women with type 2 diabetes., Methods: Participants (N = 279) were randomized to usual care (UC) or Mediterranean Lifestyle Program, a lifestyle change intervention aimed at the behavioral risk factors (eating patterns, physical activity, stress management, and social support) affecting risk for CHD in postmenopausal women with type 2 diabetes., Results: In original and intent-to-treat analyses, Mediterranean Lifestyle Program participants showed significantly greater improvement in dietary behaviors, physical activity, stress management, perceived support, and weight loss at 6 months compared to UC., Conclusions: This study demonstrated the effectiveness of the Mediterranean Lifestyle Program in improving self-care among women with type 2 diabetes, showed that postmenopausal women could make comprehensive lifestyle changes, and provided evidence that a program using social-cognitive strategies and peer support can be used to modify multiple lifestyle behaviors.

This paper describes a randomized study to evaluate the effects of a comprehensive lifestyle management intervention for 279 postmenopausal women with type 2 diabetes who are at elevated risk for coronary heart disease (CHD). The intervention, called the Mediterranean Lifestyle Trial, is focused on dietary factors, physical activity, social support and stress management. The Mediterranean Lifestyle Trial relies on a synthesis of Social Cognitive Theory and Social Ecologic Theory, as well as goal-systems theory, to explicitly inform the lifestyle intervention and to address maintenance. Thus, the trial should help illuminate the theoretical mechanisms responsible for lifestyle change. Primary outcome variables are dietary, stress management and physical activity behavior change, quality of life, and CHD-related biological risk factors. Hypothesized mediating variables include self-efficacy, coping, and social and environmental support. Following the initial 6-month intervention, participants in the intervention condition are randomized to one of two groups designed to enhance maintenance of effects: either a peer-led support group or a personalized multilevel community resources maintenance condition. Unlike the peer group, the personalized approach focuses on multiple levels of community resources to promote healthful lifestyle change. Because this research focuses on issues of generalization and translation to practice, the RE-AIM evaluation framework is being used to evaluate Reach, Effectiveness, Adoption, Implementation and Maintenance. This framework will help to translate research into practice by directing researchers' attention to important but seldom-investigated strategies for enhancing longer-term maintenance. Specifically, the study tests how long-term maintenance may be improved through the use of existing community resources, an intervention based on multiple environmental factors and multiple lifestyle behaviors, and lay leaders versus personalized professional support.