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Preventive interventions are critical to improving health equity among American Indian (AI) populations, yet interventions that promote physical activity (PA) among AI populations are scarce. This research addresses the research-to-practice gap by informing the adaption and implementation process of evidence-based interventions (EBIs) among rural AI older adults. We used a community-based approach and an Indigenous-focused adaptation theoretical framework. Qualitative, semi-structured interviews elicited detailed information on preferences for PA intervention among rural AI older adults. We applied a collaborative directed content analysis strategy, and established trustworthiness and relevance using an inter-rater reliability process and member checking. We conducted 21 interviews, all participants identified as AI, the mean age was 66 years (SD = 7.6), and 57% were female. Themes characterized contextual and cultural intervention considerations for adapting and implementing evidence-based PA interventions in rural AI older adults. Key findings included an emphasis on social and community interaction, strategies for targeted engagement, preference for group format, pairing PA sessions with shared meals, and inclusiveness in the PA intervention across ability levels and age groups. This study identified opportunities for adaptation of PA-focused EBIs among rural AI older adults. Findings can be applied to support the adaptation and implementation of effective and relevant PA-focused preventive interventions among this population which is at high risk for chronic disease and health disparities.

The COVID-19 pandemic increased reliance on virtual care for patients with persistent asthma.This retrospective cohort study assessed changes from in-person to virtual care during the pandemic. In patients with persistent asthma, compared with the same period before the pandemic.Kaiser Permanente Colorado members aged 18 to 99 years with persistent asthma were evaluated during two periods (March to October 2019 and March to October 2020). Comparison of asthma exacerbations (hospitalizations, emergency department visits, and courses of oral prednisone) and asthma medication metrics were evaluated between the two periods and by type of care received during the pandemic (no care, virtual care only, in-person care only, or a mix of virtual and in-person care). Population characteristics by type of care received during the pandemic were also evaluated.Among 7,805 adults with persistent asthma, those who used more virtual care or sought no care during the pandemic were younger and had fewer comorbidities, mental health diagnoses, or financial barriers. Exacerbations decreased (0.264 to 0.214; P.001) as did courses of prednisone (0.213 to 0.169). Asthma medication adherence (0.53 to 0.54; P.001) and the asthma medication ratio, a quality-of-care metric (0.755 to 0.762; P = .019), increased slightly. Patients receiving a mix of in-person and virtual care had the highest rate of exacerbations (0.83) and a lower asthma medication ratio (0.74) despite having the highest adherence (.57).Despite an increase in virtual care, asthma exacerbations decreased except among individuals who received both in-person and virtual care, likely because they had more severe disease.

Introduction: Understanding, categorizing, and using implementation science theories, models, and frameworks is a complex undertaking. The issues involved are even more challenging given the large number of frameworks and that some of them evolve significantly over time. As a consequence, researchers and practitioners may be unintentionally mischaracterizing frameworks or basing actions and conclusions on outdated versions of a framework. Methods: This paper addresses how the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework has been described, summarizes how the model has evolved over time, and identifies and corrects several misconceptions. Results: We address 13 specific areas where misconceptions have been noted concerning the use of RE-AIM and summarize current guidance on these issues. We also discuss key changes to RE-AIM over the past 20 years, including the evolution to Pragmatic Robust Implementation and Sustainability Model, and provide resources for potential users to guide application of the framework. Conclusions: RE-AIM and many other theories and frameworks have evolved, been misunderstood, and sometimes been misapplied. To some degree, this is inevitable, but we conclude by suggesting some actions that reviewers, framework developers, and those selecting or applying frameworks can do to prevent or alleviate these problems.

BACKGROUND: Use of digital communication technology has shown potential to improve asthma adherence and outcomes. Few studies have looked at patient preference around mode of medication reminders used to improve and maintain asthma medication adherence. OBJECTIVE: To determine if, in a population already receiving automated medication reminders, offering a choice for preferred mode of reminder (text, email, phone) would improve their adherence and asthma outcomes over a 1-year period. METHODS: This was a pragmatic, randomized controlled trial conducted at Kaiser Permanente Colorado involving 7522 adult patients with persistent asthma. Study patients were randomized to receive usual care or their choice of medication reminder. Differences between the 2 groups in both medication adherence and asthma outcomes were then assessed over the following year. RESULTS: Only 30% of those offered a choice of medication reminder modality responded by making a choice, with 52% preferring text messaging. There was less of a decrease in adherence rate over the 1-year period in those who made a choice regarding the mode of medication refill reminder. There was no difference in asthma outcomes between those who did make a choice compared with those who did not make a choice regarding the mode of medication refill reminder. CONCLUSION: In a patient population already receiving medication reminders, offering a choice about what type of technology-enabled asthma medication reminder patients wanted did not improve outcomes but did enable a subgroup to better maintain their medication adherence.

Use of digital communication technologies (DCT) shows promise for enhancing outcomes and efficiencies in asthma care management. However, little is known about the impact of DCT interventions on healthcare personnel requirements and costs, thus making it difficult for providers and health systems to understand the value of these interventions. This study evaluated the differences in healthcare personnel requirements and costs between usual asthma care (UC) and a DCT intervention (Breathewell) aimed at maintaining guidelines-based asthma care while reducing health care staffing requirements. We used data from a pragmatic, randomized controlled trial conducted in a large integrated health system involving 14,978 patients diagnosed with asthma. To evaluate differences in staffing requirements and cost between Breathewell and UC needed to deliver guideline-based care we used electronic health record (EHR) events, provider time tracking surveys, and invoicing. Differences in cost were reported at the patient and health system level. The Breathewell intervention significantly reduced personnel requirements with a larger percentage of participants requiring no personnel time (45% vs. 5%, p < .001) and smaller percentage of participants requiring follow-up outreach (44% vs. 68%, p < .001). Extrapolated to the total health system, cost for the Breathewell intervention was $16,278 less than usual care. The intervention became cost savings at a sample size of at least 957 patients diagnosed with asthma. At the population level, using DCT to compliment current asthma care practice presents an opportunity to reduce healthcare personnel requirements while maintaining population-based asthma control measures.

Nurses are in an ideal position to talk to their patients of reproductive age about alcohol use and encourage the prevention of alcohol-exposed pregnancies. Effective conversations can be efficiently included in the clinical encounter to identify alcohol misuse and offer appropriate follow-up. This report presents results of an environmental scan of resources relevant to nursing professionals and nurses' role in addressing alcohol misuse. Gaps in nursing education and practice guidelines with regard to defining the nursing role in preventing alcohol-exposed pregnancies were revealed. Findings identified a need to promote adoption among nurses of evidence-based preventive practices to prevent alcohol misuse.

The U.S. Preventive Services Task Force recommends that clinicians adopt universal alcohol screening and brief intervention as a routine preventive service for adults, and efforts are underway to support its widespread dissemination. The likelihood that healthcare systems will sustain this change, once implemented, is under-reported in the literature. This article identifies factors that were important to postimplementation sustainability of an evidence-based practice change to address alcohol misuse that was piloted within three diverse primary care organizations. The Centers for Disease Control and Prevention funded three academic teams to pilot and evaluate implementation of alcohol screening and brief intervention within multiclinic healthcare systems in their respective regions. Following the completion of the pilots, teams used the Program Sustainability Assessment Tool to retrospectively describe and compare differences across eight sustainability domains, identify strengths and potential threats to sustainability, and make recommendations for improvement. Health systems varied across all domains, with greatest differences noted for Program Evaluation, Strategic Planning, and Funding Stability. Lack of funding to sustain practice change, or data monitoring to promote fit and fidelity, was an indication of diminished Organizational Capacity in systems that discontinued the service after the pilot. Early assessment of sustainability factors may identify potential threats that could be addressed prior to, or during implementation to enhance Organizational Capacity. Although this study provides a retrospective assessment conducted by external academic teams, it identifies factors that may be relevant for translating evidence-based behavioral interventions in a way that assures that they are sustained within healthcare systems.

This article uses the RE-AIM framework to evaluate the feasibility of implementing Enhance Mobility (EM), a tailored, evidence-informed group exercise and walking program for older adults w...

The trajectory of aging is profoundly impacted by the physical and social environmental contexts in which we live. While “top–down” policy activities can have potentially wide impacts on such contexts, they often take time, resources, and political will, and therefore can be less accessible to underserved communities. This article describes a “bottom–up”, resident-engaged method to advance local environmental and policy change, called Our Voice, that can complement policy-level strategies for improving the health, function, and well-being of older adults. Using the World Health Organization’s age-friendly cities global strategy, we describe the Our Voice citizen science program of research that has specifically targeted older adults as environmental change agents to improve their own health and well-being as well as that of their communities. Results from 14 Our Voice studies that have occurred across five continents demonstrate that older adults can learn to use mobile technology to systematically capture and collectively analyze their own data. They can then successfully build consensus around high-priority issues that can be realistically changed and work effectively with local stakeholders to enact meaningful environmental and policy changes that can help to promote healthy aging. The article ends with recommended next steps for growing the resident-engaged citizen science field to advance the health and welfare of all older adults.

Background Due to a history of oppression and lack of culturally competent services, lesbian, gay, bisexual and transgender (LGBT) seniors experience barriers to accessing social services. Tailoring an evidence-based ageing in place intervention to address the unique needs of LGBT seniors may decrease the isolation often faced by this population. Objective To describe practices used in the formation of a community-based participatory research (CBPR), partnership involving social workers, health services providers, researchers and community members who engaged to establish a LGBT ageing in place model called Seniors Using Supports To Age In Neighborhoods (SUSTAIN). Methods A case study approach was employed to describe the partnership development process by reflecting on past meeting minutes, progress reports and interviews with SUSTAIN's partners. Results Key partnering practices utilized by SUSTAIN included (i) development of a shared commitment and vision; (ii) identifying partners with intersecting spheres of influence in multiple communities of identity (ageing services, LGBT, health research); (iii) attending to power dynamics (e.g. equitable sharing of funds); and (iv) building community capacity through reciprocal learning. Although the partnership dissolved after 4 years, it served as a successful catalyst to establish community programming to support ageing in place for LGBT seniors. Conclusion Multi-sector stakeholder involvement with capacity to connect communities and use frameworks that formalize equity was key to establishing a high-trust CBPR partnership. However, lack of focus on external forces impacting each partner (e.g. individual organizational strategic planning, community funding agency perspectives) ultimately led to dissolution of the SUSTAIN partnership even though implementation of community programming was realized.

This qualitative study conducted by a community-research partnership used multiple types of data collection to examine variables relevant for LGBTQ older adults who wished to age in place in their urban Denver neighborhood. Focus groups, interviews, and a town hall meeting were used to identify barriers and supports to aging in place. Participants (N = 73) identified primarily as lesbian or gay, aged 50-69, and lived with a partner. Ageism, heterosexism, and cisgenderism emerged as cross-cutting themes that negatively impact access to health care, housing, social support, home assistance, and legal services. Resilience from weathering a lifetime of discrimination was identified as a strength to handle aging challenges. Recommendations for establishing an aging in place model included establishing welcoming communities and resource centers and increasing cultural competence of service providers. This study provides a unique contribution to understanding the psychosocial, medical, and legal barriers for successfully aging in place.

Background:Midlife and older adults use shopping malls for walking, but little research has examined mall characteristics that contribute to their walkability.Methods:We used modified versions of the Centers for Disease Control and Prevention (CDC)-Healthy Aging Research Network (HAN) Environmental Audit and the System for Observing Play and Recreation in Communities (SOPARC) tool to systematically observe 443 walkers in 10 shopping malls. We also observed 87 walkers in 6 community-based nonmall/nongym venues where older adults routinely walked for physical activity.Results:All venues had public transit stops and accessible parking. All malls and 67% of nonmalls had wayfinding aids, and most venues (81%) had an established circuitous walking route and clean, well-maintained public restrooms (94%). All venues had level floor surfaces, and one-half had benches along the walking route. Venues varied in hours of access, programming, tripping hazards, traffic control near entrances, and lighting.Conclusions:Despite diversity in location, size, and purpose, the mall and nonmall venues audited shared numerous environmental features known to promote walking in older adults and few barriers to walking. Future research should consider programmatic features and outreach strategies to expand the use of malls and other suitable public spaces for walking.

Advances in mobile technology provide an opportunity to deliver in-the-moment interventions to individuals with alcohol use disorders, yet availability of effective “apps” that deliver evidence-based interventions is scarce. The authors developed an immediately available, portable, smartphone-based intervention system whose purpose is to provide stand-alone, self-administered assessment and intervention. In this article, the authors describe how theory and empirical evidence, combined with smartphone functionality, contributed to the construction of a user-friendly, engaging alcohol intervention. With translation in mind, the authors discuss how they selected appropriate intervention components including assessments, feedback and tools, that work together to produce the hypothesized outcomes.

Health information technology has great potential to promote efficiency in patient care and increase patient-provider communication, and patient engagement in their treatment. This paper explored qualitatively what patients with type 2 diabetes want from electronic resources that are designed to support their diabetes self-management. Data were collected via interviews and focus groups from managed care patients who had completed participation in either a web-based (MyPath) or in-person group-based (iViva Bien!) longitudinal diabetes self-management study. Content analysis identified common themes that highlighted participant interest in virtual and electronic programs to support diabetes self-management goals, and their desired content and features. Eighteen iViva Bien! participants completed telephone interviews and 30 MyPath participants attended seven focus groups in 2010-2011. All participants expressed a preference for face-to-face contact; however, most participants were also interested in using technology as a tool to support daily diabetes self-management decisions and to receive tailored information. Choice of technology, personalized instruction on how to use program features, and the ability to exchange information with their healthcare team were desired by all participants. Participants were divided on whether virtual social support networks should be closed to friends and family, should include other program members (peers), or should be open to anyone with diabetes. Participants aged 65 and older stressed the desire for technical support. What patients wanted from technology is real-time assistance with daily behavioral decision-making, ability to share information with their healthcare team, connections with others for support, and choice.

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.

Type 2 diabetes is a costly chronic illness that is increasing in prevalence and associated with significant health problems, including heart disease.1 Furthermore, type 2 diabetes and heart disease share multiple lifestyle risk factors that tend to co-occur for many adults.2 Research has established the health benefits of adopting Mediterranean-style eating practices,3 engaging in physical activity,4,5 managing stress,6,7 and using social-environmental support to initiate and sustain health-related behaviors.8–10 Nevertheless, multiple–risk-factor intervention studies are rare11-13 and sorely needed, particularly to understand their potential to reach and benefit underserved populations. Multiple-behavior–change interventions appear necessary in light of the co-occurrence of risk factors,2 yet they are complex and demanding for both service providers and patients. Providers must have multiple competencies or the resources to assemble an interdisciplinary team with expertise in nutrition, exercise, smoking cessation, stress management, and motivational strategies. They must weigh the costs and benefits of sequential and simultaneous approaches to changing multiple behaviors, although thus far, those approaches seem to produce comparable effects.14 Patients must comprehend many intervention methods and devote sufficient effort to each. The purpose of this article is to describe the structure and content of the Mediterranean Lifestyle Program (MLP) and its results during 7 years of assessments, as well as a cultural adaptation of the MLP for Latinas (iViva Bien!) that was offered to members of a large health maintenance organization (HMO) and a community health center in the Denver, Colo., metropolitan area and its results during 2 years of evaluation. The adaptation of the MLP into iViva Bien! was intended to expand the generalizability of the intervention and to test its application in collaboration with health organizations, two important steps in developing an intervention that can be disseminated …

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.

Physical activity has been identified as one of three key health behaviors impacting the major chronic diseases of aging that are increasingly responsible for a substantial proportion of global mortality. Although the scientific evidence indicates that the health and quality of life effects of a physically active lifestyle extend across the life course, midlife and older adults represent the most inactive portion of the population. Among the objectives of this review are to discuss the benefits of an active lifestyle, particularly for older adults; highlight the major issues and challenges currently facing the physical activity and aging field; and explore the types of directions for science, policy, and practice that could positively impact the significant physical inactivity challenge facing a growing number of countries worldwide.

Background Nurses are likely to encounter opportunities to engage patients in alcohol interventions, yet few have received preparation for this work. Although screening procedures are relatively straightforward and easily utilized by nurse professionals, developing a personalized, brief, and effective response to promote behavior change for indicated cases is a clinical skill that, for many nurses, requires deliberate effort to acquire [1,2]. To support development of alcohol screening and brief intervention (SBI) skills among nurses and implement alcohol SBI as a routine practice, Alaska Public Health Nursing (PHN) collaborated with the Arctic FASD Regional Training Center at the University of Alaska Anchorage. The objective is to describe ongoing training needs for nurses conducting alcohol SBI.

INTRODUCTION: Walking is a preferred and recommended physical activity for middle-aged and older adults, but many barriers exist, including concerns about safety (ie, personal security), falling, and inclement weather. Mall walking programs may overcome these barriers. The purpose of this study was to summarize the evidence on the health-related value of mall walking and mall walking programs. METHODS: We conducted a scoping review of the literature to determine the features, environments, and benefits of mall walking programs using the RE-AIM framework (reach, effectiveness, adoption, implementation, and maintenance). The inclusion criteria were articles that involved adults aged 45 years or older who walked in indoor or outdoor shopping malls. Exclusion criteria were articles that used malls as laboratory settings or focused on the mechanics of walking. We included published research studies, dissertations, theses, conference abstracts, syntheses, nonresearch articles, theoretical papers, editorials, reports, policy briefs, standards and guidelines, and nonresearch conference abstracts and proposals. Websites and articles written in a language other than English were excluded. RESULTS: We located 254 articles on mall walking; 32 articles met our inclusion criteria. We found that malls provided safe, accessible, and affordable exercise environments for middle-aged and older adults. Programmatic features such as program leaders, blood pressure checks, and warm-up exercises facilitated participation. Individual benefits of mall walking programs included improvements in physical, social, and emotional well-being. Limited transportation to the mall was a barrier to participation. CONCLUSION: We found the potential for mall walking programs to be implemented in various communities as a health promotion measure. However, the research on mall walking programs is limited and has weak study designs. More rigorous research is needed to define best practices for mall walking programs' reach, effectiveness, adoption, implementation, and maintenance. Language: en

OBJECTIVE—There is a well-documented gap between diabetes care guidelines and the services received by patients in most health care settings. This report presents 12-month follow-up results from a computer-assisted, patient-centered intervention to improve the level of recommended services patients received from a variety of primary care settings. RESEARCH DESIGN AND METHODS—A total of 886 patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program. Physicians were stratified and randomized to intervention or control conditions and evaluated on two primary outcomes: number of recommended laboratory screenings and recommended patient-centered care activities completed from the National Committee on Quality Assurance/American Diabetes Association Provider Recognition Program (PRP). Secondary outcomes were evaluated using the Problem Areas in Diabetes 2 quality of life scale, lipid and HbA1c levels, and the Patient Health Questionnaire-9 depression scale. RESULTS—The program was well implemented and significantly improved both the number of laboratory assays and patient-centered aspects of diabetes care patients received compared with those in the control condition. There was overall improvement on secondary outcomes of lipids, HbA1c, quality of life, and depression scores; between-condition differences were not significant. CONCLUSIONS—Staff in small, mixed-payer primary care offices can consistently implement a patient-centered intervention to improve PRP measures of quality of diabetes care. Alternative explanations for why these process improvements did not lead to improved outcomes, and suggested directions for future research are discussed.

Interactive health technologies (IHTs), whether used as an adjunct to clinical care or as a stand-alone program, provide a means to efficiently deliver both standardized information and tailored health interventions to a large number of patients. This article describes the benefits and drawbacks to the use of read-only memory compact disks (CD-ROMs) to facilitate diabetes self-management, using the experience from two efficacy trials with CD-ROMs as the primary modality for intervention. The CD-ROMs were designed to promote health behavior change and prevent complications by increasing attention to diabetes care guidelines and providing tailored self-management plans to patients with type 2 diabetes.Lessons learned from these two studies are shared to answer the question:does the use of CD-ROMs as an intervention tool address the key barriers to using a self-management approach in primary care? We conclude by discussing the advantages and limitations of using CD-ROMs to deliver health interventions, along with recommendations for maximizing the potential of IHTs.

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.

OBJECTIVETo evaluate associations between psychosocial and social-environmental variables and diabetes self-management, and diabetes control.RESEARCH DESIGN AND METHODSBaseline data from a type 2 diabetes self-management randomized trial with 463 adults having elevated BMI (M = 34.8 kg/m2) were used to investigate relations among demographic, psychosocial, and social-environmental variables; dietary, exercise, and medication-taking behaviors; and biologic outcomes.RESULTSSelf-efficacy, problem solving, and social-environmental support were independently associated with diet and exercise, increasing the variance accounted for by 23 and 19%, respectively. Only diet contributed to explained variance in BMI (β = −0.17, P = 0.0003) and self-rated health status (β = 0.25, P < 0.0001); and only medication-taking behaviors contributed to lipid ratio (total–to–HDL) (β = −0.20, P = 0.0001) and A1C (β = −0.21, P < 0.0001).CONCLUSIONSInterventions should focus on enhancing self-efficacy, problem solving, and social-environmental support to improve self-management of diabetes.

It is clear that there is a need to pay attention to the contextual factors that will promote the broad adoption, successful implementation, and long-term sustainability of community-based environment and policy change. Reviews of both clinical and community-based interventions have shown that information about the intervention setting, how a program or policy is implemented, and how it is institutionalized are reported much less often than individual-level factors.1 Thus, as best practices for active living are identified, there is an equally important opportunity to identify ways to ensure that these best practices will be adopted, implemented, and maintained. A key strength of the Active Living by Design (ALbD) program is its inclusion of a variety of types of communities. By purposively including both urban and rural communities, variation in climate and geographic locations, and both low- and moderate-income settings, this greatly enhances confidence that success is generalizable. Robustness of results across different types of communities is an important criterion for widespread public health impact, and the ALbD program receives high marks on this dimension. The 5P model (preparation, promotion, programs, policy, and physical projects) used in ALbD2 should enhance adoption and implementation. Like the 5A’s model for smoking cessation and chronic illness self-management,3 this alliterative mnemonic facilitates understanding and reduces the complexity of multi-level interventions—one of Rogers’s key criteria for successful adoption.4 The 5P model should also help implementation as the framework serves as a reminder to community partners that it is important to address all of the Ps. It is clear from the papers in this issue that this framework was widely used by communities. A first step to increasing the likelihood that the individuals who are reached (i.e., those who are exposed to the ALbD interventions) include those who could most benefit is through the strategic composition of the community partnership. Use of a multi-level socio-ecologic approach to identify those partners who represent, or have access to, the venues and organizations in which the target population(s) live, work, and play will greatly increase the likelihood of success. The variety of partners included in the ALbD communities, such as city planners, law enforcement, schools, residents, and neighborhood associations, bodes well for decreasing any skepticism that the partnership has a pre-determined agenda and for identifying issues and solutions that resonate with the target population.5 Another way to assure a broad reach for strategies that are ultimately sustained is to implement changes at the policy (e.g., zoning laws, school physical education policies) and environment (e.g., biking and pedestrian infrastructure) levels. While strategic use of programs is appropriate to build awareness, knowledge, and skills, assuring that organizations will continue to offer and finance them into the future is often challenging, particularly during tight times. Policies and environment changes, while more likely to be sustained once implemented, also require upkeep, enforcement, and periodic evaluation to assure they are effective. Although far fewer resources are required on an ongoing basis than for program activities, an unfunded policy mandate or a well-maintained trail that cannot be accessed without a car may not reach those most in need. Of course, the real test of maintenance will be another 5 or 10 years to see if these communities have integrated ALbD goals, values, and activities into their vision of their communities. Encouraging shared leadership among partners, such as partner-led workgroups, will help to sustain partner engagement and foster adoption and maintenance of strategies beyond the grant.6 In addition, to the degree that partners are able to identify with and integrate the ALbD vision into their own organizations, the work of the partnership will continue even if the partnership is disbanded. It will be of interest to see how many of the partnerships established for ALbD have continued or evolved into something different. One example of how the 5P framework has already achieved maintenance and the related goal of generalization is the report that the framework has been used by ALbD communities for other grants and projects.

Advances in mobile technology provide an opportunity to deliver in-the-moment interventions to individuals with alcohol use disorders, yet availability of effective “apps” that deliver evidence-based interventions is scarce. We developed an immediately available, portable, smartphone-based intervention system whose purpose is to provide stand-alone, self-administered assessment and intervention. In this paper, we describe how theory and empirical evidence, combined with smartphone functionality contributed to the construction of a user-friendly, engaging alcohol intervention. With translation in mind, we discuss how we selected appropriate intervention components including assessments, feedback and tools, that work together to produce the hypothesized outcomes.

Latinas with type 2 diabetes are in need of culturally sensitive interventions to make recommended long-term lifestyle changes and reduce heart disease risk. To test the longer-term (24-month) effects of a previously successful, culturally adapted, multiple-health-behavior-change program, iViva Bien!, 280 Latinas were randomly assigned to usual care or iViva Bien!. Treatment included group meetings to promote a culturally adapted Mediterranean diet, physical activity, supportive resources, problem solving, stress-management practices, and smoking cessation. iViva 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 iViva 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).

Culturally appropriate interventions are needed to assist Latinas in making multiple healthful lifestyle changes.The purpose of this study was to test a cultural adaptation of a successful multiple health behavior change program, ¡Viva Bien!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.¡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.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.

The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework, which provides a practical means of evaluating health interventions, has primarily been used in studies focused on changing individual behaviors. Given the importance of the built environment in promoting health, using RE-AIM to evaluate environmental approaches is logical. We discussed the benefits and challenges of applying RE-AIM to evaluate built environment strategies and recommended modest adaptations to the model. We then applied the revised model to 2 prototypical built environment strategies aimed at promoting healthful eating and active living. We offered recommendations for using RE-AIM to plan and implement strategies that maximize reach and sustainability, and provided summary measures that public health professionals, communities, and researchers can use in evaluating built environment interventions.

Background: Increased access to the Internet and the availability of efficacious eHealth interventions offer great promise for assisting adults with diabetes to change and maintain health behaviors. A key concern is whether levels of engagement in Internet programs are sufficient to promote and sustain behavior change. Objective: This paper used automated data from an ongoing Internet-based diabetes self-management intervention study to calculate various indices of website engagement. The multimedia website involved goal setting, action planning, and self-monitoring as well as offering features such as "Ask an Expert" to enhance healthy eating, physical activity, and medication adherence. We also investigated participant characteristics associated with website engagement and the relationship between website use and 4-month behavioral and health outcomes. Methods: We report on participants in a randomized controlled trial (RCT) who were randomized to receive (1) the website alone (n = 137) or (2) the website plus human support (n = 133) that included additional phone calls and group meetings. The website was available in English and Spanish and included features to enhance engagement and user experience. A number of engagement variables were calculated for each participant including number of log-ins, number of website components visited at least twice, number of days entering self-monitoring data, number of visits to the "Action Plan" section, and time on the website. Key outcomes included exercise, healthy eating, and medication adherence as well as body mass index (BMI) and biological variables related to cardiovascular disease risk. Results: Of the 270 intervention participants, the average age was 60, the average BMI was 34.9 kg/m(2), 130 (48%) were female, and 62 (23%) self-reported Latino ethnicity. The number of participant visits to the website over 4 months ranged from 1 to 119 (mean 28 visits, median 18). Usage decreased from 70% of participants visiting at least weekly during the first 6 weeks to 47% during weeks 7 to 16. There were no significant differences between website only and website plus support conditions on most of the engagement variables. In total, 75% of participants entered self-monitoring data at least once per week. Exercise action plan pages were visited more often than medication taking and healthy eating pages (mean of 4.3 visits vs 2.8 and 2.0 respectively, P

PURPOSE In 30 small, independent primary care practices, we examined the association between clinician-reported use of elements of the Chronic Care Model (CCM) and diabetic patients’ hemoglobin A1c (HbA1c) and lipid levels and self-reported receipt of care. METHODS Ninety clinicians (60 physicians, 17 nurse-practitioners, and 13 physician’s assistants) completed a questionnaire assessing their use of elements of the CCM on a 5-point scale (never, rarely, occasionally, usually, and always). A total of 886 diabetic patients reported their receipt of various diabetes care services. We computed a clinical care composite score that included patient-reported assessments of blood pressure, lipids, microalbumin, and HbA1c; foot examinations; and dilated retinal examinations. We computed a behavioral care composite score from patient-reported support from their clinician in setting self-management goals, obtaining nutrition education or therapy, and receiving encouragement to self-monitor their glucose. HbA1c values and lipid profiles were obtained by independent laboratory assay. We used multilevel regression models for analyses to account for the hierarchical nature of the data. RESULTS Clinician-reported use of elements of CCM was significantly associated with lower HbA1c values (P = .002) and ratios of total cholesterol to high-density lipoprotein cholesterol (P = .02). For every unit increase in clinician-reported CCM use (eg, from “rarely” to “occasionally”), there was an associated 0.30% reduction in HbA1c value and 0.17 reduction in the lipid ratio. Clinician use of the CCM elements was also significantly associated with the behavioral composite score (P = .001) and was marginally associated with the clinical care composite score (P = .07). CONCLUSIONS Clinicians in small independent primary care practices are able to incorporate elements of the CCM into their practice style, often without major structural change in the practice, and this incorporation is associated with higher levels of recommended processes and better intermediate outcomes of diabetes care.

A major problem in the dissemination of most interventions found to be efficacious is that they are of limited or unknown generalizability.To document the "robustness," or external validity, of a computer-assisted diabetes self-management program across different patient characteristics, healthcare settings (mixed payer vs health maintenance organization), intervention staff, and outcomes.A randomized controlled trial evaluating a computer-assisted behavior change program for adult patients with type 2 diabetes mellitus (n = 217) vs a computerized health risk assessment.Outcomes were identified using the RE-AIM framework and included program adoption among physicians, reach across patient groups, implementation, and behavioral (fat intake and physical activity) and biological (glycosylated hemoglobin and lipid levels) effectiveness measures.The program achieved 41% patient participation, variable adoption across healthcare settings (76% of health maintenance organization physicians vs 18% of non-health maintenance organization physicians participated), good implementation, and improvement in behavioral outcomes. There were few significant interactions between treatment condition and patient characteristics, type of healthcare setting, or interventionist experience on effectiveness measures.Patients and physicians were willing to participate in a computer-assisted dietary and physical activity goal-setting intervention, although participation varied by healthcare setting. Interventionists from different backgrounds successfully delivered the intervention, and the results appear robust across various patient and delivery characteristics.

There is a dearth of information on the extent to which diabetic patients receive care congruent with the chronic care model (CCM) and evidence-based behavioral counseling. This study evaluates a new instrument to fill this gap.A heterogeneous sample of 363 type 2 diabetic patients completed the original Patient Assessment of Chronic Illness Care (PACIC), along with additional items that allowed it to be scored according to the "5As" (ask, advise, agree, assist, and arrange) model of behavioral counseling. We evaluated relationships between survey scores and patient characteristics, quality of diabetes care, and self-management.Findings replicated those of the initial PACIC validation study but with a much larger sample of diabetic patients and more Latinos. Areas of CCM activities reported least often were goal setting/intervention tailoring and follow-up/coordination. The 5As scoring revealed that patients were least likely to receive assistance with problem solving and arrangement of follow-up support. Few demographic or medical characteristics were related to PACIC or 5As scores, but survey scores were significantly related to quality of diabetes care received and level of physical activity.The PACIC and the new 5As scoring method appear useful for diabetic patients. Its use is encouraged in future research and quality improvement studies.

OBJECTIVE: There is a well-documented gap between diabetes care guidelines and the services received by patients in almost all health care settings. This project reports initial results from a computer-assisted, patient-centered intervention to improve the level of recommended services received by patients from a wide variety of primary care providers. DESIGN AND SETTINGS: Eight hundred eighty-six patients with type 2 diabetes under the care of 52 primary care physicians participated in the Diabetes Priority Program. Physicians were stratified and randomized to intervention or control conditions and evaluated on 2 primary outcomes: number of recommended laboratory screenings and recommended patient-centered care activities completed. Secondary outcomes were evaluated using the Problem Areas in Diabetes scale and the Patient Health Questionnaire (PHQ)-9 depression scale, and the RE-AIM framework was used to evaluate potential for dissemination. RESULTS: The program was well-implemented and significantly improved both number of recommended laboratory assays (3.4 vs 3.1; P

Background The Institute of Medicine recommends changing organizational policy as a key element of evidence-based practice (EBP) implementation; however, policy change alone may be insufficient to change provider practice behavior [1,2]. Engaging key organizational stakeholders in the policy change process may foster buy-in, particularly if the policy is piloted and refined alongside the new practice. As part of a two-year initiative funded by CDC to implement routine alcohol screening and brief intervention (SBI) into primary care settings, the Alaska Section of Public Health Nursing (PHN) collaborated with the University of Alaska Anchorage to pilot alcohol SBI policy and procedures in three clinics prior to systemwide dissemination.

Background The University of Alaska Anchorage partnered with the State of Alaska, Section of Public Health Nursing (PHN) to pilot routine alcohol screening and brief intervention (aSBI) in three of their 22 public health centers (PHCs) prior to system-wide dissemination. During this two-year project funded by the Centers for Disease Control and Prevention, the university research team facilitated aSBI implementation through collaborative planning with PHN leadership, providing training for nurses to conduct aSBI, and maintaining contact with PHN staff. Nurses at the pilot sites participated in regular phone calls with members of the research team acting as change facilitators. A Plan-Do-Study-Act approach was used to refine implementation protocols throughout the pilot.