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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.

Technology-based interventions, including telephone applications and web-based programs targeting hazardous alcohol and substance use, have the potential to provide alternative intervention options to millions of individuals in need and to reduce the public health burden associated with hazardous alcohol and substance use. Addiction—Comprehensive Health Enhancement Support System is a smartphone-based recovery support system designed originally to function in the traditional addiction treatment system with patients leaving residential treatment for alcohol use disorder. Relapse is so prevalent that some theorists believe it should be considered a normal or expected aspect of treatment for substance use disorders. Cognitive-Behavioral Therapy (CBT) is widely recognized as an empirically supported treatment for substance use disorders, but it has proven challenging to move CBT to clinical practice with high levels of fidelity. Many individuals appear to have difficulty admitting to others, even in a treatment context, that they have a substance problem.

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.

The prevalence of substance use disorders remains high in the United States and healthcare professionals are largely ill-equipped to intervene with patients experiencing substance misuse or use disorders. To address this issue, substance abuse intervention curricula such as Screening, Brief Intervention, and Referral to Treatment (SBIRT) are being integrated into university healthcare programs through the use of simulation to provide healthcare students with the necessary skills to address patient substance use. Teaching SBIRT with simulation provides students with an authentic clinical environment in which to learn and refine clinical skills. Simulation also supports reflective practice by providing an opportunity for instructors and peers to directly observe and provide feedback on students' patient care. Additionally, students can review (through video recording) and reflect on their own performance within the simulation to build self-awareness and improve their skills and approach to clinical work. This paper describes how SBIRT simulation was integrated into nursing, psychology, and social work curricula at a medium-sized northwest university and a family medicine residency program in the same community. Satisfaction with SBIRT simulation as well as students’ perceived change in confidence in addressing substance use was recorded. Overall, instructors, students, and medical residents were highly satisfied with simulation experiences. Students and medical residents also reported increases in understanding of and confidence in executing SBIRT. Simulation implementation strategies and resources are provided and discussed.

Standardized screening, brief intervention, and referral to treatment (SBIRT) is effective when used by health care professionals to assess, educate, and intervene to address risky alcohol use. To accelerate SBIRT training within academic settings, the Substance Abuse and Mental Health Services Administration funded implementation of its SBIRT curriculum to promote its use by future health care professionals. We report on how SBIRT content was implemented within nursing, social work, psychology, and family medicine residency programs at a state university. The reach, effectiveness, adoption, implementation, and maintenance (RE-AIM) evaluation framework was used to compare delivery of SBIRT curriculum across health professions. Survey data measured changes in student knowledge, confidence, and responsibility to use SBIRT for alcohol and drugs, pre- and post-SBIRT training. Twelve months postgraduation follow-up surveys examined maintenance of outcomes and SBIRT use in practice. Observational data explored fidelity and adaptations made to curriculum content and delivery logistics. Results indicated that instructor adoption, fidelity, and format varied across health professional training programs, with adaptations made to improve fit, role alignment, and cultural relevance. Despite variation in curriculum delivery, students demonstrated significant gains in knowledge and confidence, ( p < .001). Key implementation and maintenance challenges included time constraints, instructor buy-in, competing accreditation requirements, and costs for using the university simulation laboratory to practice SBIRT. Strengths supporting maintenance included flexibility to adapt curriculum, department champions, and electronic resources to support curriculum delivery. Results suggest that adaptations maximizing the feasibility and fit of SBIRT within existing courses enhanced its adoption and maintenance potential without sacrificing effectiveness.

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.

Mall walking has been a popular physical activity for decades. However, little is known about why mall managers support these programs or why adults choose to walk. Our study aim was to describe mall walking programs from the perspectives of walkers, managers, and leaders. Twenty-eight walkers, 16 walking program managers, and six walking program leaders from five states participated in a telephone or in-person semi-structured interview (N = 50). Interview guides were developed using a social-ecological model. Interviews were recorded, transcribed verbatim, and analyzed thematically. All informants indicated satisfaction with their program and environmental features. Differences in expectations were noted in that walkers wanted a safe, clean, and social place whereas managers and leaders felt a need to provide programmatic features. Given the favorable walking environments in malls, there is an opportunity for public health professionals, health care organizations, and providers of aging services to partner with malls to promote walking.

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.

Over the past 2 decades, more women in the United States are engaging in excessive alcohol use, including women of reproductive age. Consuming alcohol in amounts greater than recommended limits is associated with an increased risk for adverse health effects, such as breast cancer, hypertension stroke, spontaneous abortion, and infertility. Any amount of alcohol use during pregnancy can result in a fetal alcohol spectrum disorder. No safe time, safe amount, or safe type of alcohol to consume during pregnancy has been identified. Contradictory beliefs about alcohol use, fear of stigmatization, and potential legal consequences can provide challenges for health care providers who communicate these risks to clients. Health care providers can help to prevent alcohol-related health issues, including alcohol-exposed pregnancies, by providing their clients with factual information about alcohol and health and client-centered options for reducing their health risks. Clinicians can use alcohol screening and brief intervention as a framework for applying the ethical principles of autonomy, veracity, beneficence, and nonmaleficence when talking with women in ways that are nonstigmatizing and supportive to help reduce their health risks and prevent alcohol-exposed pregnancies.

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.

Background. Efforts to predict success in chronic disease management programs have been generally unsuccessful. Objective. To identify patient subgroups associated with success at each of 6 steps in a diabetes self-management (DSM) program. Design. Using data from a randomized trial, recursive partitioning with signal detection analysis was used to identify subgroups associated with 6 sequential steps of program success: agreement to participate, completion of baseline, initial website engagement, 4-month behavior change, later engagement, and longer-term maintenance. Setting. The study was conducted in 5 primary care clinics within Kaiser Permanente Colorado. Patients. Different numbers of patients participated in each step, including 2076, 544, 270, 219, 127, and 89. All measures available were used to address success at each step. Intervention. Participants were randomized to receive either enhanced usual care or 1 of 2 Internet-based DSM programs: 1) self-administered, computer-assisted self-management and 2) the self-administered program with the addition of enhanced social support. Measurements. Two sets of potential predictor variables and 6 dichotomous outcomes were created. Results. Signal detection analysis differentiated successful and unsuccessful subgroups at all but the final step. Different patient subgroups were associated with success at these different steps. Demographic factors (education, ethnicity, income) were associated with initial participation but not with later steps, and the converse was true of health behavior variables. Limitations. Analyses were limited to one setting, and the sample sizes for some of the steps were modest. Conclusions. Signal detection and recursive partitioning methods may be useful for identifying subgroups that are more or less successful at different steps of intervention and may aid in understanding variability in outcomes.

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 need for practical, efficient and broad-reaching diabetes self-management interventions that can produce changes in lifestyle behaviours such as healthy eating and weight loss. The objective of this study was to evaluate such a computer-assisted intervention. Methods: Type 2 diabetes primary care patients ( n=335) from fee-for-service and health maintenance organization settings were randomized to social cognitive theory-based tailored self-management (TSM) or computer-aided enhanced usual care (UC). Intervention consisted of computer-assisted self-management assessment and feedback, tailored goal-setting, barrier identification, and problem-solving, followed by health counsellor interaction and follow-up calls. Outcomes were changes in dietary behaviours (fat and fruit/vegetable intake), haemoglobin A1c (HbA1c), lipids, weight, quality of life, and depression. Results: TSM patients reduced dietary fat intake and weight significantly more than UC patients at the 2-month follow-up. Among patients having elevated levels of HbA1c, lipids or depression at baseline, there were consistent directional trends favouring intervention, but these differences did not reach significance. The intervention proved feasible and was implemented successfully by a variety of staff. Conclusions: This relatively low-intensity intervention appealed to a large, generally representative sample of patients, was well implemented, and produced improvement in targeted behaviours. Implications of this practical clinical trial for dissemination are discussed.

Background Current healthcare evidence relies on relatively narrow efficacy data to make decisions about program impact. This paper illustrates the application of impact indices derived from the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework that takes a broader perspective and includes issues important to decision makers, such as reach, adoption, and cost. Methods Composite RE-AIM indices that summarize impact and cost efficiency at the individual participant and setting levels are used to compare two different diabetes self-management support approaches. One study, the Diabetes Priority (DP) program, involved 886 diabetes patients from 30 primary care offices, and relied on usual clinical staff for program implementation. The other study, Diabetes Health Connection (DHC), involved 335 diabetes patients in both HMO and fee-for-service settings, and used health education staff. Results The DP performed better on the setting-level impact index, but the programs produced similar results on individual-level impact. The DP had a greater reach (50% vs 38%); was more effective at the initial follow-up (median effect size [ES]=0.23 vs 0.17); and had greater impact consistency across various populations. The DHC performed better on several indices, including higher physician office adoption (20% vs 6%) and staff adoption (79% vs 70%), and there was less variability among intervention staff on protocol implementation (median ES=0.0 vs 0.50). Conclusions Greater use of indices focused on public health and external validity criteria could help identify programs most likely to have a meaningful impact on population health and to fit local settings and priorities.

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.

PURPOSE this study reports on methods and strategies employed to increase participation rates in diabetes interventions and discusses the reach and representativeness of the Diabetes Priority Program. METHODS A passive mail-out procedure was used to contact patients of participating primary care physicians. Patients who did not return the refusal postcard were contacted. Several attempts were made to contact potential participants. Brochures, "wrong number" postcards, posters, and reports for clinic staff were strategies used to increase participation. RESULTS The recruitment process resulted in a participation rate of 83% among patients who were contacted and eligible. These participants appeared to be representative of both nonparticipants and persons with diabetes in Colorado. In contrast, a low percentage of primary care physicians, estimated at 3%, took part in the program despite efforts to make the program brief, nonintrusive, and compatible with usual care. CONCLUSIONS Recruitment is currently challenging and will become even more difficult with the privacy regulations that affect healthcare research and the public distrust of solicitations. To increase participation rates, it is important that the clinic staff promotes and supports the program, and that participant lists are accurate and adequate in size.

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.

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.

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 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.

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.