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A remote (telephone and tool kit) chronic pain program was studied using the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. This 6-week pilot took place in underserved communities in Cleveland, Ohio. We determined reach by the diversity of the population, nearly 50% Black and mostly low income. Effectiveness over 7 weeks was shown with validated instruments (depression, pain, sleep, quality of life, self-rated health, and self-efficacy). Changes in pain, depression, and self-efficacy were significant. ( p < .01). Remote implementation was accomplished by sending participants a box of materials (book, exercise and relaxation CDs, a self-test, and tip sheets). Participants also participated in peer-facilitated, weekly, scripted telephone calls. Maintenance was demonstrated as the study site has offered nine additional programs with more plan. In addition, 60 additional organizations are now offering the program. This proof-of-concept study offers an alternate to in-person chronic pain self-management program delivery.

Introduction: We aimed to evaluate the resonance of public health messages promoting early detection of dementia in adult Latinos with a living older adult loved one. Method: We conducted a mixed-methods study with focus groups and surveys to evaluate eight messages encouraging Latino adults to accompany their older loved one for cognitive assessment. Qualitative data were transcribed and coded, and thematic analysis was conducted. We used descriptive statistics for quantitative data. Results: Participants suggested that messages need to be translated into Spanish and images need to be more natural, present balance between positive and serious facial expressions, show more ethnic/racial diversity, and show family members other than the parents. Five major sociocultural themes affected how the messages were received: stigma, gender roles, the importance of the mother figure, guilt, and family togetherness. Conclusion: Public health messages targeting cultural values are needed to effectively encourage early dementia detection in Latinos. Findings can be used to adapt culturally appropriate public health messages encouraging early dementia detection in Latinos.

HIGHLIGHTS • What is the primary question addressed by this study? Can PEARLS, a brief, home-based intervention focused on problem solving treatment and behavioral activation for low-income older adults living with depression, improve social connectedness for underserved older populations? • What is the main finding of this study? PEARLS participants significantly improved on all three social connectedness constructs (social interactions and satisfaction with social support; perceived isolation; loneliness) six-months after PEARLS enrollment. Though most improvements persisted during early COVID-19 pandemic, additional supports may be needed for older persons with complex health and social needs. • What is the meaning of the finding? PEARLS is a promising intervention for increasing social connectedness among underserved older adults living with depression., Objective To evaluate PEARLS effectiveness for increasing social connectedness among underserved older adults with depression. Design Multi-site, pre-post single-group evaluation. Setting Community-based social service organizations (N=16) in five U.S. states, purposively sampled for maximum variation of participants and providers. Participants 320 homebound older adults (mean(SD) age 72.9(9.6), 79% female, 44% people of color, 81% low-income, 61% living alone, average four chronic conditions) with clinically significant depression (PHQ-9 mean(SD) 12.7(4.6)). Intervention 4-6 month home-based depression care management model delivered by trained front-line providers. Measurements Brief validated social connectedness scales: Duke Social Support Index 10-item (DSSI-10), PROMIS-Social Isolation (6-item), UCLA-Loneliness (3-item); sociodemographic and health measures. Results At baseline, PEARLS participants overall and with >/=1 of the following characteristics were less socially connected: younger (50-64), white, LGBTQ+, not partnered, not caregiving, living alone, financial limitations, chronic conditions, and/or recently hospitalized. Six-months post-PEARLS enrollment, participants significantly increased social interactions and satisfaction with social support (DSSI-10 t[312]=5.2, p

Objectives: To describe how physical therapy providers and their patients interact and communicate about physical activity (PA), and explore the barriers and facilitators to patient involvement in PA programs. Method: We conducted 39 direct observations of patient visits with physical therapy providers and 30 telephone interviews with physical therapists (PTs). We conducted a thematic analysis of observation field notes and interview transcripts. Results: PTs and patients engaged in several behaviors to build rapport, discussed PA type and frequency, and exchanged advice and information about PA. Barriers to patient participation in PA programs included low instrumental support, physical limitations, lack of motivation and confidence, and lack of knowledge about available programs. Facilitators included emotional support from friends, peers, and family, and encouragement and information-sharing from providers. Discussion: PTs play an important role in improving older adult PA and could be instrumental in reducing barriers to PA participation.

Background. Depression and social isolation are believed to be strongly interrelated. Social isolation can lead to depression because of reduced human contact and connectivity. Depression can cause withdrawal from interpersonal encounters and fuel feelings of social isolation. Despite causality, this study aimed to examine the relationship between depression and social isolation risk among older adults. Methods. Using an internet-delivered survey, data were analyzed from a national sample of 4,082 adults age 60 years and older. The survey intended to validate the Upstream Social Isolation Risk Screener (U-SIRS), a 13-item screener (Cronbach’s alpha=0.80) to assesses physical, emotional, and social support aspects of social isolation. Theta scores for the U-SIRS served as the primary independent variable, which were generated using Item Response Theory. Depression was the dependent variable for this study, which was identified using the PHQ-2 (scores of 3+ indicated risk for depression). Binary logistic regression was used to identify factors associated with depression. Results. Participants’ average age was 69.6(±5.2) years, 59% of participants were female, and 9% met depression criterion. Depressive symptomology and U-SIRS theta scores were positively significantly correlated (r=0.56, P

Objectives Supportive organizational breastfeeding policies can establish enabling environments for breastfeeding. In this qualitative study we identify facilitators and barriers to the development, adoption, and implementation of supportive breastfeeding policies and practices in four influential sectors for breastfeeding women: hospitals, clinics, early care and education settings, and worksites. Methods We interviewed 125 individuals representing 110 organizations in Washington State about their breastfeeding policy development and implementation process between August 2014 and February 2015. Greenhalgh's diffusion of innovations framework guided the interviews and qualitative analysis. Results Breastfeeding policy facilitators across the sectors include national and state laws and regulations, performance tracking requirements, and an increasingly supportive sociopolitical climate; barriers include limited resources and appreciation about the need for breastfeeding policies, and certain organizational characteristics such as workforce age. Despite broad support for breastfeeding, organizations differed on perceptions about the usefulness of written breastfeeding policies. Personal breastfeeding experiences of policy makers and staff affect organizational breastfeeding policies and practices. Conclusions for Practice Supportive organizational systems and environments are built through effective policy development processes; public health can support breastfeeding policy development and assure a coordinated continuum of care by leveraging federal health care policy requirements, building networks to support training and collaboration, and disseminating strategies that reflect the personal nature of breastfeeding.

The authors developed and evaluated a peer-driven engagement intervention to reach older veterans, veteran spouses, and widowed veteran-spouses with an evidence-based depression management program called the Program to Encourage Active, Rewarding Lives (PEARLS). The authors interviewed key informants in veteran service organizations to design the intervention and trained former PEARLS veterans/spouses/widowed veteran-spouses as peer educators (“champions”). The authors interviewed champions to identify facilitators and barriers to implementing the intervention. Facilitators included enjoying and finding honor in their role and using personal experiences to describe PEARLS. Barriers included competing priorities, difficulty addressing barriers raised by peers, and complicated materials. Findings can inform future efforts to engage older veterans in depression treatment.

Objective The challenges posed by people living with multiple chronic conditions are unique for people with dementia and other significant cognitive impairment. There have been recent calls to action to review the existing literature on co-occurring chronic conditions and dementia in order to better understand the effect of cognitive impairment on disease management, mobility, and mortality. Methods This systematic literature review searched PubMed databases through 2011 (updated in 2016) using key constructs of older adults, moderate-to-severe cognitive impairment (both diagnosed and undiagnosed dementia), and chronic conditions. Reviewers assessed papers for eligibility and extracted key data from each included manuscript. An independent expert panel rated the strength and quality of evidence and prioritized gaps for future study. Results Four thousand thirty-three articles were identified, of which 147 met criteria for review. We found that moderate-to-severe cognitive impairment increased risks of mortality, was associated with prolonged institutional stays, and decreased function in persons with multiple chronic conditions. There was no relationship between significant cognitive impairment and use of cardiovascular or hypertensive medications for persons with these comorbidities. Prioritized areas for future research include hospitalizations, disease-specific outcomes, diabetes, chronic pain, cardiovascular disease, depression, falls, stroke, and multiple chronic conditions. Conclusions This review summarizes that living with significant cognitive impairment or dementia negatively impacts mortality, institutionalization, and functional outcomes for people living with multiple chronic conditions. Our findings suggest that chronic-disease management interventions will need to address co-occurring cognitive impairment. Copyright © 2017 John Wiley & Sons, Ltd.

Background The burden of non-communicable diseases (NCDs) is increasing in low- and middle-income countries (LMICs) where NCDs cause 4:5 deaths, disproportionately affect poorer populations, and carry a large economic burden. Digital interventions can improve NCD management for these hard-to-reach populations with inadequate health systems and high cell-phone coverage; however, there is limited research on whether digital health is reaching this potential. We conducted a process evaluation to understand challenges and successes from a digital health intervention trial to support Cambodians living with NCDs in a peer educator (PE) program. Methods MoPoTsyo, a Cambodian non-governmental organization (NGO), trains people living with diabetes and/or hypertension as PEs to provide self-management education, support, and healthcare linkages for better care management among underserved populations. We partnered with MoPoTsyo and InSTEDD in 2016-2018 to test tailored and targeted mHealth mobile voice messages and eHealth tablets to facilitate NCD management and clinical-community linkages. This cluster randomized controlled trial (RCT) engaged 3,948 people and 75 PEs across rural and urban areas. Our mixed methods process evaluation was guided by RE-AIM to understand impact and real-world implications of digital health. Data included patient (20) and PE interviews (6), meeting notes, and administrative datasets. We triangulated and analyzed data using thematic analysis, and descriptive and complier average causal effects statistics (CACE). Results Reach: intervention participants were more urban (66% vs. 44%), had more PE visits (39 vs. 29), and lower uncontrolled hypertension [12% and 7% vs. 23% and 16% uncontrolled systolic blood pressure (SBP) and diastolic blood pressure (DBP)]. Adoption: patients were sent mean [standard deviation (SD)] 30 [14] and received 14 [8] messages; 40% received no messages due to frequent phone number changes. Effectiveness: CACE found clinically but not statistically significant improvements in blood pressure and sugar for mHealth participants who received at least one message vs. no messages. Implementation: main barriers were limited cellular access and that mHealth/eHealth could not solve structural barriers to NCD control faced by people in poverty. Maintenance: had the intervention been universally effective, it could be paid for from additional revolving drug fund revenue, new agreements with mobile networks, or the government. Conclusions Evidence for digital health to improve NCD outcomes in LMICs are limited. This study suggests digital health alone is insufficient in countries with low resource health systems and that high cell phone coverage did not translate to access. Adding digital health to an NCD peer network may not significantly benefit an already effective program; mHealth may be better for hard-to-reach populations not connected to other supports. As long as mHealth remains an individual-level intervention, it will not address social determinants of health that drive outcomes. Future digital health research and practice to improve NCD management in LMICs requires engaging government, NGOs, and technology providers to work together to address barriers.

According to recent guidelines, 46% of U.S. adults have high blood pressure (i.e., hypertension). Traditionally addressed in clinical settings, only 54% of adults successfully manage their hypertension. Community–clinical partnerships that facilitate medication adherence and lifestyle changes are promising avenues to achieve population-level blood pressure control. We examined partnerships for blood pressure control in Washington State, their facilitators and barriers, and ways public health departments could foster partnerships. We conducted 41 semistructured interviews with clinic staff, community-based organization (CBO) staff, pharmacy staff, and community health workers (CHWs). The Centers for Disease Control and Prevention–adapted Himmelman Collaboration Continuum, which describes five levels of partnership intensity, guided our thematic analysis. We found variation across sectors in partnership frequency and intensity. Clinic and pharmacy staff reported fewer partnerships than CBO staff and CHWs, and mostly either low or very high intensity partnerships. CBO staff and CHWs described partnerships at each intensity level. Trust and having a shared mission facilitated partnerships. Competition, lack of time, limited awareness of resources, and lack of shared health records constituted barriers to partnership. Bringing potential partners together to discuss shared goals, increasing technological integration, and building awareness of resources may help bridge clinical and community silos and improve population-level blood pressure control.

Background Hypertension and diabetes represent the first and third highest contributors to global disability. While mobile health (mHealth) messaging programs have rapidly increased in low- and middle-income countries (LMIC), adaptations for specific patient health needs is a new approach to manage chronic conditions. Objective The primary aim of this study is to develop and test an mHealth communication intervention using electronic data capture (by tablet) and voice messaging to improve hypertension and diabetes self-management in Cambodia. The secondary aim is to share results with the Cambodian Ministry of Health and development partners to inform health policy and develop strategies for hypertension and diabetes control. Methods The study design is a cluster randomized controlled clinical trial randomizing each of 75 Community peer educators (PEs), trained and coordinated by MoPoTsyo Patient Information Center in Phnom Penh, into one of 3 groups of 25 (approximately 60 patients each) to receive either tablet+messages, tablet only, or no intervention (control). The total sample within each group includes 25 clusters and approximately 1500 patients located in 7 Operational Districts in rural regions or urban slums in Cambodia. The interventions (groups 1 and 2) were compared with usual PE monitoring without the tablet or mHealth messaging interventions. Focus groups and informant interviews were conducted to develop messages according to specific themes-medications adherence, laboratory testing, physician visits, obesity, smoking, and general lifestyle issues. Using the data received at monthly PE monitoring meetings, patients will receive specific messages based on their individual health challenges. Following the intervention completion, clinical and process outcomes will be compared with baseline metrics between groups. Results PEs were randomized in July 2017, and the intervention was implemented in September 2017 through June 2018. Analyses are underway. Conclusions This project is unique in its combination of electronic data transfer, which can be accessed immediately, with voice messages most relevant to individual patients' needs. Positive results will indicate the value of using targeted messaging in patient-specific, self-management issues to improve hypertension and diabetes control. International registered report identifier (irrid) DERR1-10.2196/11614.

BACKGROUND In many low- and middle-income countries (LMICs), heart disease and stroke are the leading causes of death as cardiovascular risk factors such as diabetes and hypertension rapidly increase. The Cambodian nongovernmental organization, MoPoTsyo, trains local residents with diabetes to be peer educators (PEs) to deliver chronic disease self-management training and medications to 14,000 people with hypertension and/or diabetes in Cambodia. We collaborated with MoPoTsyo to develop a mobile-based messaging intervention (mobile health; mHealth) to link MoPoTsyo’s database, PEs, pharmacies, clinics, and people living with diabetes and/or hypertension to improve adherence to evidence-based treatment guidelines. OBJECTIVE This study aimed to understand the facilitators and barriers to chronic disease management and the acceptability, appropriateness, and feasibility of mHealth to support chronic disease management and strengthen community-clinical linkages to existing services. METHODS We conducted an exploratory qualitative study using semistructured interviews and focus groups with PEs and people living with diabetes and/or hypertension. Interviews were recorded and conducted in Khmer script, transcribed and translated into the English language, and uploaded into Atlas.ti for analysis. We used a thematic analysis to identify key facilitators and barriers to disease management and opportunities for mHealth content and format. The information-motivation-behavioral model was used to guide data collection, analysis, and message development. RESULTS We conducted six focus groups (N=59) and 11 interviews in one urban municipality and five rural operating districts from three provinces in October 2016. PE network participants desired mHealth to address barriers to chronic disease management through reminders about medications, laboratory tests and doctor’s consultations, education on how to incorporate self-management into their daily lives, and support for obstacles to disease management. Participants preferred mobile-based voice messages to arrive at dinnertime for improved phone access and family support. They desired voice messages over texts to communicate trust and increase accessibility for persons with limited literacy, vision, and smartphone access. PEs shared similar views and perceived mHealth as acceptable and feasible for supporting their work. We developed 34 educational, supportive, and reminder mHealth messages based on these findings. CONCLUSIONS These mHealth messages are currently being tested in a cluster randomized controlled trial (#1R21TW010160) to improve diabetes and hypertension control in Cambodia. This study has implications for practice and policies in Cambodia and other LMICs and low-resource US settings that are working to engage PEs and build community-clinical linkages to facilitate chronic disease management.

Background Evidence-based programs (EBPs) are used across disciplines to integrate research into practice and improve outcomes at the individual and/or community level. Despite widespread development and implementation of EBPs, many programs are not sustained beyond the initial implementation period due to many factors, including workforce turnover. This scoping review summarizes research on the impact of workforce turnover on the sustainability of EBPs and recommendations for mitigating these impacts. Methods We searched 10 databases for articles that focused on an EBP and described an association between workforce turnover and the sustainment or sustainability of the program. We created a data abstraction tool to extract relevant information from each article and applied the data abstraction tool to all included articles to create the dataset. Data were mapped and analyzed using the program sustainability framework (PSF). Results and Discussion A total of 30 articles were included in this scoping review and mapped to the PSF. Twenty-nine articles described impacts of workforce turnover and 18 articles proposed recommendations to address the impacts. The most frequent impacts of workforce turnover included increased need for training, loss of organizational knowledge, lack of EBP fidelity, and financial stress. Recommendations to address the impact of workforce turnover included affordable and alternative training modalities, the use of champions or volunteers, increasing program alignment with organizational goals, and generating diverse funding portfolios. Conclusion The sustainment of EBPs is critical to ensure and maintain the short- and long-term benefits of the EBP for all participants and communities. Understanding the impacts of workforce turnover, a determinant of sustainability, can create awareness among EBP-implementing organizations and allow for proactive planning to increase the likelihood of program sustainability.

Objectives Breastfeeding promotion is increasingly recognized as a key public health strategy. Policies can promote breastfeeding by creating supportive environments and addressing challenges. In 2014, the Washington State legislature considered bills to create a voluntary recognition system for breastfeeding-friendly hospitals, clinics, worksites and childcare settings. These Breastfeeding-Friendly Washington (BFW) bills (SB 6298 and HB 2329) did not pass. Methods The purpose of this case study was to analyze the policy development process for the BFW bills using the Advocacy Coalition Framework. Data were collected through semi-structured interviews with key stakeholders in the state policy process, and document review. We used thematic analysis to identify deductive and inductive themes. Results Though all policy actors indicated general support for breastfeeding, two main coalitions (proponents and opponents) diverged in their support of the BFW bills as policy solutions to address barriers to breastfeeding. We conducted 29 interviews with mainly bill proponents, and 54 documents confirmed data about bill opponents. Proponents supported the bills given increasingly strong evidence of breastfeeding's benefits and that public policy could address environmental challenges to breastfeeding. Opponents saw the bills as government overreach into the private matter of choosing to breastfeed. Opposition to the bills came late in the session, and proponents felt opponents' messaging misconstrued the intent of the legislation. Conclusions for Practice Key learnings for developing breastfeeding-friendly state policies include analyzing differences between proponents' and opponents' beliefs, framing advocacy messages beyond individuals and health, expanding the coalition outside of traditional health entities, and anticipating the opposition.

BackgroundSubstantial evidence supports the effectiveness of peer educator programs for diabetes management in low- and middle-income countries. However, little is known about peer educators' impact relative to other treatment components such as medication and physician consultation. In Cambodia, the non-governmental organization MoPoTsyo organizes four services for people with diabetes: self-management training through peer educator visits, lab tests, physician consultations, and low-cost medicines. Our aims were to 1) quantify MoPoTsyo participant utilization of each program service and 2) define the relationship between each program service and glycemic control.MethodsWe conducted a retrospective cohort study among 4,210 MoPoTsyo participants, using data collected by MoPoTsyo from 2006-2016. Independent variables assessed were medication adherence, number of peer educator visits, number of physician consultations, and number of lab tests. A multiple logistic regression model was used to evaluate the association between these disease management services and glycemic control-fasting plasma glucose ≤130 mg/dl or post-prandial glucose ≤180 mg/dl-based on most recent glucose level. The model was adjusted for baseline demographic and disease characteristics.FindingsParticipants with 12 or more peer educator visits per year had a 35% higher odds of glycemic control relative to participants with 4 or fewer visits (odds ratio 1.35, 95% CI: 1.08-1.69; p = 0.009), after adjustment for utilization of other treatment components (medication adherence, number of physician visits, number of lab tests), follow-up time, and demographic and disease characteristics. Better adherence to medications and a greater number of lab tests per year were also associated with a higher odds of glycemic control after adjustment. Number of physician consultations was not associated with glycemic control after adjustment.ConclusionsThis study demonstrates a positive association between peer educator utilization and glycemic control incremental to other elements of diabetes management. These results suggest that peer educators may be a valuable addition to comprehensive diabetes management programs in low- and middle-income countries even when other health care services are accessible. The associations identified in this research warrant further prospective studies to explore the causal impact of peer educators on glycemic control relative to other disease management components.

Background In many low- and middle-income countries (LMICs), heart disease and stroke are the leading causes of death as cardiovascular risk factors such as diabetes and hypertension rapidly increase. The Cambodian nongovernmental organization, MoPoTsyo, trains local residents with diabetes to be peer educators (PEs) to deliver chronic disease self-management training and medications to 14,000 people with hypertension and/or diabetes in Cambodia. We collaborated with MoPoTsyo to develop a mobile-based messaging intervention (mobile health; mHealth) to link MoPoTsyo’s database, PEs, pharmacies, clinics, and people living with diabetes and/or hypertension to improve adherence to evidence-based treatment guidelines. Objective This study aimed to understand the facilitators and barriers to chronic disease management and the acceptability, appropriateness, and feasibility of mHealth to support chronic disease management and strengthen community-clinical linkages to existing services. Methods We conducted an exploratory qualitative study using semistructured interviews and focus groups with PEs and people living with diabetes and/or hypertension. Interviews were recorded and conducted in Khmer script, transcribed and translated into the English language, and uploaded into Atlas.ti for analysis. We used a thematic analysis to identify key facilitators and barriers to disease management and opportunities for mHealth content and format. The information-motivation-behavioral model was used to guide data collection, analysis, and message development. Results We conducted six focus groups (N=59) and 11 interviews in one urban municipality and five rural operating districts from three provinces in October 2016. PE network participants desired mHealth to address barriers to chronic disease management through reminders about medications, laboratory tests and doctor’s consultations, education on how to incorporate self-management into their daily lives, and support for obstacles to disease management. Participants preferred mobile-based voice messages to arrive at dinnertime for improved phone access and family support. They desired voice messages over texts to communicate trust and increase accessibility for persons with limited literacy, vision, and smartphone access. PEs shared similar views and perceived mHealth as acceptable and feasible for supporting their work. We developed 34 educational, supportive, and reminder mHealth messages based on these findings. Conclusions These mHealth messages are currently being tested in a cluster randomized controlled trial (#1R21TW010160) to improve diabetes and hypertension control in Cambodia. This study has implications for practice and policies in Cambodia and other LMICs and low-resource US settings that are working to engage PEs and build community-clinical linkages to facilitate chronic disease management.

The National Council on Aging is partnering with the Evidence-Based Leadership Council (EBLC) to support program developers/administrators to enhance research and/or delivery systems and supports. EBLC is a collaborative of organizations who develop and administer EBPs, and who have successfully implemented and sustained multiple programs. We work with NCOA, ACL/AoA, and other partners to support organizations develop, deliver, and scale EBPs. With support from ACL/AoA and NCOA, EBLC is providing free technical assistance to applicants who do not met EBP criteria to help support further EBP development. Applicants are given detailed feedback from reviewers about areas that need to be strengthened: research methods (e.g., sample size, measures, study duration, design) or dissemination and implementation infrastructure (e.g., training and implementation manuals, quality assurance checklists, data management tools, tracking program locations). Our overall aim is to expand EBPs available to promote healthy aging and manage chronic diseases across diverse settings and populations.

BACKGROUND Hypertension and diabetes represent the first and third highest contributors to global disability. While mobile health (mHealth) messaging programs have rapidly increased in low- and middle-income countries (LMIC), adaptations for specific patient health needs is a new approach to manage chronic conditions. OBJECTIVE The primary aim of this study is to develop and test an mHealth communication intervention using electronic data capture (by tablet) and voice messaging to improve hypertension and diabetes self-management in Cambodia. The secondary aim is to share results with the Cambodian Ministry of Health and development partners to inform health policy and develop strategies for hypertension and diabetes control. METHODS The study design is a cluster randomized controlled clinical trial randomizing each of 75 Community peer educators (PEs), trained and coordinated by MoPoTsyo Patient Information Center in Phnom Penh, into one of 3 groups of 25 (approximately 60 patients each) to receive either tablet+messages, tablet only, or no intervention (control). The total sample within each group includes 25 clusters and approximately 1500 patients located in 7 Operational Districts in rural regions or urban slums in Cambodia. The interventions (groups 1 and 2) were compared with usual PE monitoring without the tablet or mHealth messaging interventions. Focus groups and informant interviews were conducted to develop messages according to specific themes—medications adherence, laboratory testing, physician visits, obesity, smoking, and general lifestyle issues. Using the data received at monthly PE monitoring meetings, patients will receive specific messages based on their individual health challenges. Following the intervention completion, clinical and process outcomes will be compared with baseline metrics between groups. RESULTS PEs were randomized in July 2017, and the intervention was implemented in September 2017 through June 2018. Analyses are underway. CONCLUSIONS This project is unique in its combination of electronic data transfer, which can be accessed immediately, with voice messages most relevant to individual patients’ needs. Positive results will indicate the value of using targeted messaging in patient-specific, self-management issues to improve hypertension and diabetes control. INTERNATIONAL REGISTERED REPOR DERR1-10.2196/11614

Background and Objectives Many barriers exist to older adult participation in physical activity, despite known benefits. Referrals from physical therapists (PTs) through clinical–community linkages offer novel, promising opportunities to increase older adult engagement in appropriate community-based physical activity programs. We assessed the capacity of PTs to participate in such linkages. Research Design and Methods We collected qualitative data using semistructured phone interviews (n = 30) with PTs across 14 states. We conducted thematic analysis using a priori themes based on the 2008 Bridging Model of Etz and colleagues: capacity to assess patient risk, ability to provide brief counseling, capacity and ability to refer, and awareness of community resources. Results Risk assessment and counseling were already part of routine practice for our respondents, but counseling could be further facilitated if PTs had more skills to engage less-motivated patients. PTs expressed a desire to refer their patients to community programs; however, barriers to referrals included lack of knowledge of and trust in community programs, and limited infrastructure for communicating with potential partners. Discussion and Implications PTs have the capacity to develop patient referral linkages with community-based physical activity programs. PT session length and content facilitates patient risk assessment and behavioral counseling. Integrating motivational techniques can help PTs engage less-motivated patients in physical activity. Systemic improvements should include innovations in communication infrastructure, identifying clinic-level champions, and in-person outreach initiated by organizations that deliver community physical activity programs.

Objectives Depression is an important precursor to dementia, but less is known about the role dementia plays in altering the course of depression. We examined whether depression prevalence, incidence, and severity are higher in those with dementia versus those with mild cognitive impairment (MCI), or normal cognition. Design Prospective cohort study using the longitudinal Uniform Data Set of the National Alzheimer's Coordinating Center (2005–2013). Setting 34 Alzheimer Disease research centers. Participants 27,776 subjects with dementia, MCI, or normal cognition. Measurements Depression status was determined by a clinical diagnosis of depression within the prior 2 years and by a Geriatric Depression Scale-Short Form score >5. Results Rates of depression were significantly higher in subjects with MCI and dementia compared with those with normal cognition at index visit. Controlling for demographics and common chronic conditions, logistic regression analysis revealed elevated depression in those with MCI (OR: 2.40 [95% CI: 2.25, 2.56]) or dementia (OR: 2.64 [95% CI: 2.43, 2.86]) relative to those with normal cognition. In the subjects without depression at the index visit (N = 18,842), those with MCI and dementia had higher probabilities of depression diagnosis 2 years post index visit than those with normal cognition: MCI = 21.7%, dementia = 24.7%, normal cognition = 10.5%. Conclusion MCI and dementia were associated with significantly higher rates of depression in concurrent as well as prospective analyses. These findings suggest that efforts to effectively engage and treat older adults with dementia will need also to address co-occurring depression.

Background Dementia or other significant cognitive impairment (SCI) are often comorbid with other chronic diseases. To promote collaborative research on the intersection of these conditions, we compiled a systematic inventory of major data resources. Methods Large data sets measuring dementia and/or cognition and chronic conditions in adults were included in the inventory. Key features of the resources were abstracted including region, participant sociodemographic characteristics, study design, sample size, accessibility, and available measures of dementia and/or cognition and comorbidities. Results 117 study data sets were identified; 53% included clinical diagnoses of dementia along with valid and reliable measures of cognition. Most (79%) used longitudinal cohort designs and 41% had sample sizes greater than 5000. Approximately 47% were European-based, 40% were US-based, and 11% were based in other countries. Conclusions Many high-quality data sets exist to support collaborative studies of the effects of dementia or SCI on chronic conditions and to inform the development of evidence-based disease management programs.

Evidence-based programs (EBPs) offer proven ways to promote health and prevent disease among older adults in their communities. EBPs are based on rigorous study of the effects of specific interventions or model programs, demonstrate consistently positive changes in important health-related and functional measures, and have tools in place to maintain program access, quality, and efficiency across diverse settings. The University of North Carolina at Chapel Hill’s Center for Health Promotion and Disease Prevention (UNC HPDP), in partnership with the Evidence-Based Leadership Collaborative (EBLC), has established a review process and Review Council to identify new community programs that meet the evidence-based program criteria established by the Administration for Community Living (ACL), one of the chief U.S. federal agencies responsible for aging programs. Approved programs are then eligible for Older Americans Act Title III-D and other discretionary funding to support organizations that deliver EBPs to improve older adult health. The review process assesses the effectiveness, outcomes, and evaluation of the program, information about program implementation, training, and other key elements for successful program dissemination. The Review Council consists of national leaders with expertise in program research, evaluation, and implementation. The review process is supported by the ACL-funded National Chronic Disease Self-Management Education and Falls Prevention Resource Centers. This session will describe the ACL evidence-based health promotion program criteria that must be met for approval; an overview of the review process; and how researchers can submit their programs for review. Time will be allowed for questions, discussion, and research to practice implications.

Background: Physical activity is important for maintaining older adult health, but a majority of older adults are not meeting recommended physical activity levels. This paper describes the protocol and participant baseline characteristics for a trial (named “PT-REFER”) to test an intervention focused on developing community-clinical linkages to increase older adult referrals from physical therapy clinics to an evidence-based group exercise program (Enhance®Fitness) (EF) offered by YMCA associations. Methods: We designed a two-arm cluster-randomized controlled trial with YMCA associations. We conducted formative research with YMCA staff and physical therapists to inform intervention format and content. The primary outcome is the number of new participants enrolled in EF over the course of 30 months. We also collect process information on cost and implementation though structured surveys and semi-structured qualitative interviews. Results: The PT-REFER intervention creates a learning collaborative for YMCA associations, which are tasked with implementing a number of capacity- and partnership-building activities over the course of seven months, and participating in monthly group technical assistance calls. We recruited 20 YMCA associations from 13 states. At baseline, the average number of EF sites per association was 3.9 and the monthly average number of new EF participants was 3.7. Conclusions: This study will test an approach to increasing the capacity of YMCAs for conducting outreach to physical therapy clinics, and evaluate the factors that may influence its implementation. As a result, it has the potential to contribute to our understanding of how to develop viable and sustainable community-clinical linkages for older adult health. Keywords: Randomized controlled trial, Physical activity, Community-clinical linkages, Older adults, Exercise

PURPOSE OF THE STUDY We partnered with 3 social service organizations to identify hard-to-reach populations, barriers to reach, and strategies for improving recruitment and retention for Program to Encourage Active, Rewarding Lives (PEARLS), a home-based depression-care management program for elders. DESIGN AND METHODS We conducted semistructured interviews with staff and former PEARLS participants. All interviews were transcribed verbatim and thematically analyzed. RESULTS Veterans, African Americans, Filipino men, other immigrants and English-language learners, old-older adults, rural communities, and people with limited education were identified as hard to reach. The themes of trust, cultural appropriateness, meet them where they are, and framing and reframing, cut across barriers to participation in PEARLS and approaches for overcoming these barriers. IMPLICATIONS Research findings will be used to inform technical assistance activities with PEARLS providers, changes to PEARLS program and training materials, and future PEARLS research activities.

There is evidence from observational studies that increasing physical activity may reduce the risk of cognitive decline in older adults. Exercise intervention trials have found conflicting results. A systematic review of physical activity and exercise intervention trials on cognition in older adults was conducted. Six scientific databases and reference lists of previous reviews were searched. Thirty studies were eligible for inclusion. Articles were grouped into intervention-outcome pairings. Interventions were grouped as cardiorespiratory, strength, and multicomponent exercises. Cognitive outcomes were general cognition, executive function, memory, reaction time, attention, cognitive processing, visuospatial, and language. An eight-member multidisciplinary panel rated the quality and effectiveness of each pairing. Although there were some positive studies, the panel did not find sufficient evidence that physical activity or exercise improved cognition in older adults. Future research should report exercise adherence, use longer study durations, and determine the clinical relevance of measures used.

To develop a comprehensive inventory of state physical education (PE) legislation, examine trends in bill introduction, and compare bill factors.State PE legislation from January 2001 to July 2007 was identified using a legislative database. Analysis included components of evidence-based school PE from the Community Guide and other authoritative sources: minutes in PE, PE activity, teacher certification, and an environmental element, including facilities and equipment. Researchers abstracted information from each bill and a composite list was developed.In total, 781 bills were analyzed with 162 enacted. Of the 272 bills that contained at least 1 evidence-based element, 43 were enacted. Only 4 bills included all 4 evidence-based elements. Of these 4, 1 was enacted. Funding was mentioned in 175 of the bills introduced (37 enacted) and an evaluation component was present in 172 of the bills (49 enacted).Based on this analysis, we showed that PE is frequently introduced, yet the proportion of bills with evidence-based elements is low. Future research is needed to provide the types of evidence required for development of quality PE legislation.

Cardiovascular disease (CVD) is the leading cause of death among Asian Americans, the majority of whom are foreign-born. However, CVD and risk factor data is sparse for specific Asian immigrant populations. To assess knowledge and understanding of CVD and risk factors within Chinese, Korean and Vietnamese immigrant populations, we conducted eight focus groups of 77 participants between 36 and 84 years old. Participants correctly identified signs and symptoms for heart attacks while knowledge about stroke was incomplete. While poor diet, lack of exercise, older age, and high cholesterol were frequently discussed as risk factors, mechanisms perceived as contributing to heart disease were influenced primarily by non-Western paradigms. Non-Western remedies were discussed in detail among Chinese and Vietnamese participants. All participants desired more information, and identified barriers to effective communication with healthcare providers. A deeper understanding of beliefs and barriers faced by Asian immigrants can help guide health promotion efforts.

The objective of this study was to explore Somali mothers’ beliefs and practices around infant feeding and education, towards developing a culturally informed infant nutrition curriculum for health providers. Four focus groups were conducted to explore: (1) beliefs about infant feeding, hunger and ideal weight; (2) feeding practices; (3) nutrition education approaches; and (4) provider/mother interactions. Thirty-seven Somali mother participants identified the following themes within these topics: (1) strategies for assessing hunger, satiety and when to feed; shared beliefs that plump babies are healthy, leading to worry about infant weight; (2) context of breast milk adequacy, difficulties breastfeeding and environmental and cultural barriers to breastfeeding, leading to nearly universal early supplementation with formula; (3) preferred education approaches include provider visits with interpreters, Somali language educational materials and advice from older, experienced family members; and (4) desired health provider skills include: listening, explaining, empathy, addressing specific concerns, repeating important information, offering preventive advice and sufficient visit time. This study presents knowledge about Somali beliefs and practices that can directly guide discussions with these families. Given that these infants appear on a trajectory towards obesity, influencing infant feeding practices in the Somali community is a good upstream approach to preventing obesity. These findings will underpin a new infant nutrition curriculum for health providers.

This study explores processes and policies that facilitate the development of community trails. With funding from Active Living Research and the research framework of the Physical Activity Policy Research Network (PAPRN), we conducted a multiple-site case study. A total of six trails in Hawaii, Massachusetts, Missouri, North Carolina, South Carolina, and Washington were chosen for study. The goals of this case study were to identify the policy influences on trail development, explore the roles of key players in trail development, and compare and contrast findings from the different trails. Trail development can be a long process. Some of the trails took over a decade to complete because of funding, opposition, and roadblocks in the form of design standard policies. Work in trail development requires a team of many players, and it is necessary to balance their varied motives to accomplish a shared overall goal. Foresight through the master planning process is also a vital component of successful trail development. Finally, community involvement is key. Communities contemplating trail development should explore the effects of policy on the trail projects reported here to proactively identify potential influence.

Background: Increasing physical activity in youth is a recommended approach to curbing the childhood obesity epidemic. One way to help increase children’s daily activity is to promote active transportation to and from school (ATS). Purpose: The purpose of this case study was to explore parental perception of and participation in, ATS initiatives. Methods: This study is part of a larger project on ATS initiatives conducted by the Physical Activity Policy Research Network. Sixty-nine key informants, including 10 parents, were interviewed at nine diverse elementary schools being studied for their ATS policies. A standard interview guide was used. The interviews were audio-recorded, transcribed, and analyzed. Results: Analysis revealed that parental support was a necessary component for ATS success. The parents' roles varied greatly. Most parents chose to become involved in ATS for a specificreason (e.g., promoting health). The parents and other key informants interviewed expressed participation bene...

Active transportation to and from school (ATS) is a viable strategy to help increase physical activity among youth. ATS can be challenging because initiatives require transdisciplinary collaboration, are influenced by the built environment and are affected by numerous policies. The purpose of this study is to identify policies and factors that influence ATS initiatives. Nine elementary schools in seven states participated in this case study. Sixty-nine stakeholders were interviewed. The interviews were transcribed, coded and analyzed using a master thematic codebook. This study identified two distinct aspects of policies: 'influential factors' which are factors that might impact policies related to ATS and 'policy actions' which are policies reported by people involved in ATS initiatives that directly affected their success. Influential factors included sidewalks, crosswalks/crossing guards, funding, personal safety concerns, advocacy group involvement and others. Policy actions included policies on school speed zone, drop-off, no-transport zones, school siting, school start/dismissal time and school choice. Despite the diversity of the schools studied, similarities included influence of built environment, safety concerns, funding and transdisciplinary collaboration. Stakeholders need to work together to stimulate action and ensure successful initiatives. Influential factors appear to be important to this process.

Objectives To present findings from an expert panel–informed literature review on community-based treatment of late-life depression. Methods A systematic literature review was conducted to appraise publications on community-based interventions for depression in older adults. The search was conducted between March and October 2005. An expert panel of mental health, aging, health services, and epidemiology researchers guided the review and voted on quality and effectiveness of these interventions. Results A total of 3543 articles were found with publication dates from 1967 to October 2005; of these, 116 were eligible for inclusion. Adequate data existed to determine effectiveness for the following interventions: depression care management, group and individual psychotherapy for depression, psychotherapy targeting mental health, psychotherapy for caregivers, education and skills training (to manage health problems besides depression; and for caregivers), geriatric health evaluation and management, exercise, and physical rehabilitation and occupational therapy. After reviewing the data, panelists rated the depression care management interventions as effective. Education and skills training, geriatric health evaluation and management, and physical rehabilitation and occupational therapy received ineffective ratings. Other interventions received mixed effectiveness ratings. Insufficient data availability and poor study quality prevented the panelists from rating several reviewed interventions. Conclusions While several well-described interventions were found to treat depression effectively in community-dwelling older adults, significant gaps still exist. Interventions that did not target depression specifically may be of benefit to older adults, but they should not be presumed to treat depression by themselves. Treating depressed elders may require a multifaceted approach to ensure effectiveness. More research in this area is needed.

Objective To present recommendations for community-based treatment of late-life depression to public health and aging networks. Methods An expert panel of mental health and public health researchers and community-based practitioners in aging was convened in April 2006 to form consensus-based recommendations. When making recommendations, panelists considered feasibility and appropriateness for community-based delivery, as well as strength of evidence on program effectiveness from a systematic literature review of articles published through 2005. Results The expert panel strongly recommended depression care management–modeled interventions delivered at home or at primary care clinics. The panel recommended individual cognitive behavioral therapy. Interventions not recommended as primary treatments for late-life depression included education and skills training, comprehensive geriatric health evaluation programs, exercise, and physical rehabilitation/occupational therapy. There was insufficient evidence for making recommendations for several intervention categories, including group psychotherapy and psychotherapies other than cognitive behavioral therapy. Conclusions This interdisciplinary expert panel determined that recommended interventions should be disseminated throughout the public health and aging networks, while acknowledging the challenges and obstacles involved. Interventions that were not recommended or had insufficient evidence often did not treat depression primarily and/or did not include a clinically depressed sample while attempting to establish efficacy. These interventions may provide other benefits, but should not be presumed to effectively treat depression by themselves. Panelists also identified primary prevention of depression as a much under-studied area. These findings should aid individual clinicians as well as public health decision makers in the delivery of population-based mental health services in diverse community settings.

Over many years, a number of academic/community partnerships have worked independently to develop, evaluate, and bring to scale participant-centered, evidence-based self-management, and health promotion programs offered in community settings for older Americans. Many of the programs developed by these partnerships have since become critical pieces of the infrastructure that supports older adults with chronic health conditions. Indeed, community-based self-management support is an integral component of the Chronic Care Model (1) illustrated in Figure ​Figure1.1. This model presents elements that can improve health outcomes for people with chronic conditions, highlighting the need for connections between healthcare and community resources, integrating patient-centered, evidence-based services that empower patients. And while these programs have succeeded in finding their place in this system working independently so far, the growth and maturation of the programs, combined with the changing environment of healthcare, have prompted new collaboration among the organizations that manage and disseminate these programs, specifically, the creation of the Evidence-Based Leadership Council (EBLC). Figure 1 The chronic care model. The EBLC is currently a group of 11 individuals representing a total of 19 evidence-based programs (Chronic Disease Self-Management suite of Programs, Matter of Balance, Enhance Fitness, Enhance Wellness, Healthy IDEAS, PEARLS, Fit & Strong!, HomeMeds, Healthy MOVES) as well as four leaders from organizations providing multiple evidence-based programs (Health Foundation of South Florida, Tarrant County Area Agency on Aging, Elder Services of the Merrimack Valley/Hebrew Senior Life, Fairhill Partners). EBLC members are employed by community-based organizations, foundations, healthcare systems, universities, and governmental entities and have been directly involved for many years in the development, evaluation, and scaling of their individual programs as well as implementation through community-based organizations. The individual program developers met informally for several years and in 2012 formed the EBLC. Over the past year, community-based organization leaders responsible for implementing multiple evidence-based programs were asked to join and be part of the council. All the programs represented by EBLC program developers meet the Administration for Community Living’s (ACL) criteria for highest level of evidence (2). In addition to the ACL, the Centers for Disease Control and Prevention (CDC) Arthritis Program (3), Substance Abuse and Mental Health Services Administration’s (SAMHSA) National Registry of Evidence-Based Programs (4), and the Agency for Healthcare Research and Quality Innovations Exchange (5) recommend these programs and find them to be the strongest of evidence-based programs (6–14). The programs represented by the EBLC are utilized by more than 1,700 agencies in the United States with nearly 400 agencies using more than one program. Together, the council represents more than 200 combined years of experience in developing, evaluating, scaling, implementing, and sustaining evidence-based self-management programs. All of the programs have proven effectiveness in published randomized controlled trial research and all programs have been brought to scale. The mission of the EBLC is to increase delivery of evidence-based programs that improve the health and well-being of diverse populations. The EBLC is committed to the following values: Person Centeredness – individuals are actively involved in programs and making a difference. Effectiveness – evidence-based programs focus on outcomes/results. Collaboration – multi-sector, multi-organizational and interdisciplinary (belief that health is achieved in the community, close to home and through broad-based collaborations). Equity and access – social justice, respect of diversity. Sustainability. The EBLC has accomplished several important tasks, including: (1) performed an initial mapping of all agencies (more than 1,700) offering any of the 19 programs as well as which programs are being offered by each agency; (2) completed a telephone survey of 15 of the agencies offering two or more programs to identify facilitators and barriers to implementation of multiple EBPs and approaches to support scaling up these programs; (3) participated in federal meetings with the ACL, the National Council on Aging Self-Management Alliance and others; and (4) held four in-person strategic planning meetings as well as smaller subcommittee meetings and bi-weekly phone calls. The EBLC believes that our community care system has now reached a stage where the status quo is no longer acceptable. As the demand for programs has increased, program infrastructures have, for the most part, not grown to meet the new demands. Each program developer has experienced challenges to keep up with increasing expectations for planning, training, and technical support, while working within the confines of their parent organization and maintaining affordability for community-based organizations. Community-based organizations have had their own set of challenges in sustaining these programs. To bring the true promise of these programs to scale, there needs to be an integration of infrastructures, and a one-stop-shop to build and to assist implementing organizations. The focus of the EBLC going forward will be to improve coordination and efficiency around marketing, technical assistance (including readiness assessment, fidelity, implementation planning, and evaluation), training, and licensing and fee structures. An EBLC website is also being developed to improve access to tools and information in each of these areas. A shared data management platform is being expanded to include all programs in the EBLC. This platform will: Facilitate the effort to identify a minimal set of common data points for all programs, which can be used to evaluate dissemination, reach and outcomes both within and across programs, Efficiently, feed a public-facing website by providing unduplicated and jointly maintained data on organizations providing EBP trainings and workshops. Offer the potential for significant gains in efficiency for program owners, who can combine information about organizations providing or interested in providing EBPs and can eliminate duplication of communications and common workflow processes (e.g., licensing, training registration). Offer the potential for significant gains in user-friendliness for organizations providing or interested in providing EBPs, by providing a single gateway to the programs (including the common website) through which adoption research, readiness assessment, licensing, and training can be handled for one or multiple programs at a time. The EBLC’s vision for the future is an ever increasing number of adults engaged in evidence-based programs that inform, activate, and empower them to improve their health and maintain independence. These programs will be embedded in a permanent, sustainable infrastructure –a national network supported by the EBLC’s technical assistance in implementation and dissemination, training, marketing, licensing, and evaluation. Bringing years of experience and expertise in disseminating participant-centered, evidence-based self-management, and health promotion programs in communities nationwide, the EBLC is poised to help many more organizations with limited resources effectively address population health challenges.

Purpose This manuscript describes the development and the preliminary evaluation of a fidelity instrument for the Program for Encouraging Active and Rewarding Lives (PEARLS), an evidence-based depression care management (DCM) program. The objective of the study was to find an effective, practical, multidimensional approach to measure fidelity of PEARLS programs to the original, research-driven PEARLS protocol in order to inform program implementation at various settings nationwide. Methods We conducted key informant interviews with PEARLS stakeholders, and held focus groups with former PEARLS clients, to identify core program components. These components were then ranked using a Q-sort process, and incorporated into a brief instrument. We tested the instrument at two time points with PEARLS counselors, other DCM program counselors, and non-DCM program counselors (n = 56) in six states. Known-groups method was used to compare findings from PEARLS programs, other DCM programs, and non-DCM programs. We asked supervisors of the counselors to complete the fidelity instrument on behalf of their counselors to affirm the validity of the results. We examined the association of PEARLS program fidelity with individual client outcomes. Results Program for Encouraging Active and Rewarding Lives providers reported the highest fidelity scores compared to DCM program providers and non-DCM program providers. The sample size was too small to yield significant results on the comparison between counselor experience and fidelity. Scores varied between PEARLS counselors and their supervisors. PEARLS program fidelity was not significantly correlated with client outcomes, suggesting that other implementation factors may have influenced the outcomes and/or that the instrument needs refinement. Conclusion Our findings suggest that providers may be able to use the instrument to assess PEARLS program fidelity in various settings across the country. However, more rigorous research is needed to evaluate instrument effectiveness.

The Program to Encourage Active, Rewarding Lives (PEARLS) began 15 years ago when the director of our local area agency on aging (AAA) approached the University of Washington Health Promotion Research Center (HPRC). She was looking for a way to serve older adults with depression, including those served by the agency’s home and community-based services (HCBS) program. Depression in this population is high, when we analyzed data from 16,032 elders receiving HCBS in Washington State in 2005, two-thirds met criteria for clinical depression (1). This partnership between the university and local aging service providers created PEARLS, a brief, home-based program to teach people tools to effectively tackle the things in their lives that overwhelm them, and to in turn, improve their depressive symptoms. These tools include a seven-step approach to problem-solving and action planning to increase physical, social, and pleasant activities. PEARLS is a structured intervention delivered in 6 to 8 one-hour visits over the course of a 4- to 5-month period. Sessions are tapered from weekly to monthly to give participants an opportunity to practice and learn the skills. More information about the program can be found at www.pearlsprogram.org. The Program to Encourage Active, Rewarding Lives (PEARLS) reduced depression and improved quality of life in two randomized controlled trials (2, 3). Since then, UW HPRC continues to work with the local AAA and other sites to help translate the evidence-based program into everyday practice. The implementation challenges are striking given that PEARLS includes several ingredients for program success: it was designed with an adopting organization as a key partner, the model trains existing staff to deliver PEARLS so new staff do not need to be hired, and the program is successfully funded in some locations through several diverse funding streams. We have learned a lot from organizations and staff that deliver PEARLS through our monthly technical assistance calls and other dissemination research and activities. We have also learned a lot from program participants through PEARLS sessions, focus groups and interviews. A selection of key learnings is provided below, organized by Glasgow’s RE-AIM framework to help improve the success of evidence-based program delivery in “real-world” settings (4–6). This framework consists of five elements – reach, effectiveness, adoption, implementation, and maintenance – that present the overall public health impact of a program or policy. It is important for programs to perform well across each of these five elements in order to maximize overall impact (7).

Purpose: Given that emotional health is a critical component of healthy aging, we undertook a systematic literature review to assess whether current interventions can positively affect older adults’ emotional health. Methods: A national panel of health services and mental health researchers guided the review. Eligibility criteria included community-dwelling older adult (aged ≥ 50 years) samples, reproducible interventions, and emotional health outcomes, which included multiple domains and both positive (well-being) and illness-related (anxiety) dimensions. This review focused on three types of interventions – physical activity, social support, and skills training – given their public health significance and large number of studies identified. Panel members evaluated the strength of evidence (quality and effectiveness). Results: In all, 292 articles met inclusion criteria. These included 83 exercise/physical activity, 25 social support, and 40 skills training interventions. For evidence rating, these 148 interventions were categorized into 64 pairings by intervention type and emotional health outcome, e.g., strength training targeting loneliness or social support to address mood. 83% of these pairings were rated at least fair quality. Expert panelists found sufficient evidence of effectiveness only for skills training interventions with health outcomes of decreasing anxiety and improving quality of life and self-efficacy. Due to limitations in reviewed studies, many intervention–outcome pairings yielded insufficient evidence. Conclusion: Skills training interventions improved several aspects of emotional health in community-dwelling older adults, while the effects for other outcomes and interventions lacked clear evidence. We discuss the implications and challenges in moving forward in this important area.

We partnered with 3 social service organizations to identify hard-to-reach populations, barriers to reach, and strategies for improving recruitment and retention for Program to Encourage Active, Rewarding Lives (PEARLS), a home-based depression-care management program for elders.We conducted semistructured interviews with staff and former PEARLS participants. All interviews were transcribed verbatim and thematically analyzed.Veterans, African Americans, Filipino men, other immigrants and English-language learners, old-older adults, rural communities, and people with limited education were identified as hard to reach. The themes of trust, cultural appropriateness, meet them where they are, and framing and reframing, cut across barriers to participation in PEARLS and approaches for overcoming these barriers.Research findings will be used to inform technical assistance activities with PEARLS providers, changes to PEARLS program and training materials, and future PEARLS research activities.

Introduction Although researchers develop evidence-based programs for public health practice, rates of adoption and implementation are often low. This qualitative study aimed to better understand implementation of the Program to Encourage Active, Rewarding Lives for Seniors (PEARLS), a depression care management program at a Seattle-King County area agency on aging. Methods We used stratified, purposive sampling in 2008 to identify 38 PEARLS clients and agency staff for participation. In 9 focus groups and 1 one-on-one interview, we asked participants to identify benefits and negative consequences of PEARLS, facilitators of and barriers to program implementation, and strategies for overcoming the barriers. Two independent researchers used thematic analysis to categorize data into key themes and subthemes. Results PEARLS benefits clients by decreasing depression symptoms and addressing other concerns, such as health problems. For staff, PEARLS provides "another set of eyes" and is a comprehensive program to help them meet clients' mental health needs. Barriers included issues with implementation process (eg, lack of communication) and the perception that eligibility criteria were more rigid than those of other agency programs. Recommended solutions included changing eligibility criteria, providing additional staff training, increasing communication, and clarifying referral procedures, roles, and responsibilities. Conclusion Barriers to PEARLS delivery discourage referrals to what is generally viewed as a beneficial program. Implementing participants' strategies for overcoming these barriers can enhance delivery of PEARLS to a greater number of older adults and help them improve their depression symptoms.

There is evidence from observational studies that increasing physical activity may reduce the risk of cognitive decline in older adults. Exercise intervention trials have found conflicting results. A systematic review of physical activity and exercise intervention trials on cognition in older adults was conducted. Six scientific databases and reference lists of previous reviews were searched. Thirty studies were eligible for inclusion. Articles were grouped into intervention-outcome pairings. Interventions were grouped as cardiorespiratory, strength, and multicomponent exercises. Cognitive outcomes were general cognition, executive function, memory, reaction time, attention, cognitive processing, visuospatial, and language. An eight-member multidisciplinary panel rated the quality and effectiveness of each pairing. Although there were some positive studies, the panel did not find sufficient evidence that physical activity or exercise improved cognition in older adults. Future research should report exercise adherence, use longer study durations, and determine the clinical relevance of measures used.

Photovoice, a qualitative methodology using photography by study participants, is an ideal tool for collecting information on awareness of cardiovascular health from the perspective of persons of different cultural backgrounds and English-speaking abilities who are often subject to health disparities. Participants of Chinese, Vietnamese, and Korean ethnicity were provided disposable cameras to photograph their perceptions of scenes promoting or acting as barriers to cardiovascular health. After the pictures were developed, they returned for a discussion in their native languages to contextualize the stories told in their photographs. Group facilitators spoke the respective native languages and transcribed sessions into English. Twenty-three adults participated (7 to 9 persons per ethnicity), ranging in age from 50 to 88 (mean 71.6) years; 48% were women. The photographs stimulated conversations of knowledge, beliefs, and concerns regarding heart disease and stroke. Issues surrounding food and exercise were most dominant across ethnic groups, focusing on fat and salt intake and the need to remain active. Cultural beliefs and issues of emotional health, including stress and loneliness related to living in a new country, were also depicted. Photovoice provided insight into perceptions of cardiovascular health that is vital for developing health promotion and education interventions in limited–English-speaking communities.

Background:Recent research demonstrates the importance of targeting the built environment to support individual physical activity, particularly for people experiencing health disparities. Master plans to promote biking and/or pedestrians (BPMPs) are a potential method for environmental change. This descriptive study aims to provide a snapshot of plan attributes and better understand demographic, social and transportation characteristics of communities with BPMPs.Methods:We collected a census sample of BPMPs from 4 states. Population and commuting data were obtained from national statistics.Results:294 master plans were included, with most plans representing municipalities. 62% of plans targeted biking only, one-fifth targeted biking and walking, and 15% targeted walking only. The sampled locations have a similar demographic profile as the overall U.S. for median age and household income, people of color, high school education, and income inequality. The degree of racial diversity of sampled communities is slightly less than the U.S. average and the percentage of people who walk to work were slightly higher.Conclusions:Given that communities with master plans have a similar profile as the overall U.S., BPMPs could feasibly be spread to communities throughout the country. Further research is planned to describe BPMPs in detail toward informing future plan development.