Peer Reviewed: A Diabetes Self-Management Program Designed for Urban American Indians

Background

Although the American Indian population has a disproportionately high rate of type 2 diabetes, little has been written about culturally sensitive self-management programs in this population.

Context

Community and clinic partners worked together to identify barriers to diabetes self-management and to provide activities and services as part of a holistic approach to diabetes self-management, called the Full Circle Diabetes Program.

Methods

The program activities and services addressed 4 components of holistic health: body, spirit, mind, and emotion. Seven types of activities or services were available to help participants improve diabetes self-management; these included exercise classes, educational classes, and talking circles.

Consequences

Ninety-eight percent of program enrollees participated in at least 1 activity, and two-thirds participated in 2 or more activities. Program participation resulted in a significant improvement in knowledge of resources for managing diabetes.

Interpretation

The Full Circle Diabetes Program developed and implemented culturally relevant resources and supports for diabetes self-management in an American Indian population. Lessons learned included that a holistic approach to diabetes self-management, community participation, and stakeholder partnerships are needed for a successful program.     

Peer Reviewed: An Internet-Based Weight Loss Intervention Initiated by a Newspaper

Background

An estimated two-thirds of North Carolina residents are overweight or obese. Mass media, such as newspapers and the Internet, can be used to broadly convey health messages for weight loss.

Context

Newspapers have traditionally been a primary source of health information for the general public. They may be uniquely suited to initiate and manage a community-based weight loss program by quickly reaching a broad readership.

Methods

Participants in the 2005 Lose to Win weight loss challenge visited the Herald-Sun Web site and anonymously entered a nickname and identification number and reported their weight each week. Participants had access to weekly articles on diet and physical activity and 4 free educational seminars.

Consequences

Of the 154 participants who self-reported weight at baseline and during the last week of the challenge, the mean weight lost was 5.9 lb.

Interpretation

Results suggest that this challenge fostered health awareness and promoted weight loss in the community. Future interventions of this type should use strategies to increase participation and retention, improve the accuracy of reported weight, and evaluate long-term success of the program. This type of intervention may be a useful first step to reach residents who are interested in losing weight.     

Peer Reviewed: Diabetes Self-Management Education in South Auckland,New Zealand, 2007-2008

Introduction

Self-management education programs seek to help patients realize that they are their own principal caregivers and that health care professionals are consultants who support them in this role. The aim of this study was to evaluate a diabetes self-management education program implemented as part of a district-wide approach in South Auckland, New Zealand, which has some of the highest prevalence rates for diabetes and is one of the most ethnically diverse and deprived regions of New Zealand.

Methods

Self-management attitudes and behaviors were monitored with the use of questionnaires before and after program implementation. Clinical outcomes such as hemoglobin A1c, body mass index, and blood pressure were also tracked before the program began and 3 months after the program ended. Participant focus groups and facilitator interviews were conducted to explore perceptions of the program.

Results

Participants showed improvement in attitudes toward their own ability to manage their diabetes; in diet, physical activity, and foot care; and in hemoglobin A1c levels 3 months after the end of participation. Participants also reduced their sense of isolation when dealing with their diabetes. However, catering to the needs of a multiethnic community is extremely resource-intensive because of the need to provide adequate language and cultural interpretation.

Conclusion

Self-management education can work in multiethnic, high-needs communities in New Zealand. Programs must ensure they enable the appropriate mechanisms and have appropriate resources to support the community''s needs.     

Peer Reviewed: Using the RE-AIM Framework to Evaluate a Physical Activity Intervention in Churches

Introduction

Health-e-AME was a 3-year intervention designed to promote physical activity at African Methodist Episcopal churches across South Carolina. It is based on a community-participation model designed to disseminate interventions through trained volunteer health directors.

Methods

We used the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework to evaluate this intervention through interviews with 50 health directors.

Results

Eighty percent of the churches that had a health director trained during the first year of the intervention and 52% of churches that had a health director trained during the second year adopted at least one component of the intervention. Lack of motivation or commitment from the congregation was the most common barrier to adoption. Intervention activities reached middle-aged women mainly. The intervention was moderately well implemented, and adherence to its principles was adequate. Maintenance analyses showed that individual participants in the intervention''s physical activity components continued their participation as long as the church offered them, but churches had difficulties continuing to offer physical activity sessions. The effectiveness analysis showed that the intervention produced promising, but not significant, trends in levels of physical activity.

Conclusion

Our use of the RE-AIM framework to evaluate this intervention serves as a model for a comprehensive evaluation of the health effects of community programs to promote health.     

Peer Reviewed: Development of a Community-Based Participatory Colorectal Cancer Screening Intervention to Address Disparities,Arkansas, 2008-2009

Background

The death rate from colorectal cancer is high and affects poor and medically underserved populations disproportionately. In the United States, health disparities are particularly acute in the Lower Mississippi River Delta region. Because many in the region have limited access to basic health care resources, they are not screened for cancer, even though screening is one of the most effective strategies to prevent colorectal cancer. Community-based participatory research is a promising approach to prevent colorectal cancer in this population.

Community Context

The Empowering Communities for Life program was implemented in 2 underserved counties in the Arkansas Lower Mississippi River Delta. The program arose from a 9-year partnership between the University of Arkansas for Medical Sciences and 9 cancer councils across Arkansas.

Methods

Empowering Communities for Life is a community-based participatory intervention designed to increase colorectal cancer screening in rural, underserved communities through fecal occult blood testing. Community and academic partners collaborated to develop research infrastructure, intervention materials and methods, and the assessment instrument.

Outcome

Project outcomes were strengthened community-academic partnerships, certification of community partners in conducting human subjects research, development of a randomized controlled design to test the intervention''s efficacy, an interactive PowerPoint presentation, an informational pamphlet, the certification of 6 lay health advisors and 22 role models to provide the intervention, and an assessment tool using an audience response system.

Interpretation

Lessons learned in working collaboratively with diverse groups include the importance of meeting face to face and listening.     

Peer Reviewed: Optimized Probability Sampling of Study Sites to Improve Generalizability in a Multisite Intervention Trial

Introduction

Studies of type 2 translation, the adaption of evidence-based interventions to real-world settings, should include representative study sites and staff to improve external validity. Sites for such studies are, however, often selected by convenience sampling, which limits generalizability. We used an optimized probability sampling protocol to select an unbiased, representative sample of study sites to prepare for a randomized trial of a weight loss intervention.

Methods

We invited North Carolina health departments within 200 miles of the research center to participate (N = 81). Of the 43 health departments that were eligible, 30 were interested in participating. To select a representative and feasible sample of 6 health departments that met inclusion criteria, we generated all combinations of 6 from the 30 health departments that were eligible and interested. From the subset of combinations that met inclusion criteria, we selected 1 at random.

Results

Of 593,775 possible combinations of 6 counties, 15,177 (3%) met inclusion criteria. Sites in the selected subset were similar to all eligible sites in terms of health department characteristics and county demographics.

Conclusion

Optimized probability sampling improved generalizability by ensuring an unbiased and representative sample of study sites.     

Peer Reviewed: Reach and Effectiveness of a Weight Loss Intervention in Patients With Prediabetes in Colorado

Introduction

Although lifestyle interventions are effective in delaying the onset of diabetes, translating these lessons to routine health care settings remains a challenge. We investigated the effectiveness of a theory-based, brief, small-group weight loss intervention for diabetes prevention. A secondary purpose was to determine the potential reach of the intervention.

Methods

A total of 14,379 members of an integrated health care organization newly diagnosed with prediabetes were potentially eligible to participate in this matched cohort longitudinal study. Of this group, 1,030 attended a 90-minute, small-group session that targeted personal action planning for healthful eating, physical activity, and weight management. We accessed electronic medical records to select 1 to 2 controls (matched on impaired fasting glucose measurement, sex, age, and body mass index) for each member who attended the small-group session (n = 760). Weight change, as recorded in the medical record, was the primary outcome. Mixed models analyses were used to adjust for matching variables and covariates and to account for individual random effects over time.

Results

Small-group participants lost significantly more weight than did their matched controls. A significantly higher proportion of small-group participants lost at least 5% of their body weight compared with controls.

Conclusion

A brief, small-group weight loss intervention was effective. However, it did not reach broadly into the population that was at risk for diabetes.     

Peer Reviewed: Spontaneous Diffusion of an Effective Skin Cancer Prevention Program Through Web-Based Access to Program Materials

Introduction

Little information exists about the diffusion of evidence-based interventions, a process that can occur naturally in organized networks with established communication channels. This article describes the diffusion of an effective skin cancer prevention program called Pool Cool through available Web-based program materials.

Methods

We used self-administered surveys to collect information from program users about access to and use of Web-based program materials. We analyzed the content of e-mails sent to the official Pool Cool Web site to obtain qualitative information about spontaneous diffusion.

Results

Program users were dispersed throughout the United States, most often learning about the program through a Web site (32%), publication (26%), or colleague (19%). Most respondents (86%) reported that their pool provided educational activities at swimming lessons. The Leader''s Guide (59%) and lesson cards (50%) were the most commonly downloaded materials, and most respondents reported using these core items sometimes, often, or always. Aluminum sun-safety signs were the least frequently used materials. A limited budget was the most commonly noted obstacle to sun-safety efforts at the pool (85%). Factors supporting sun safety at the pool centered around risk management (85%) and health of the pool staff (78%).

Conclusion

Diffusion promotes the use of evidence-based health programs and can occur with and without systematic efforts. Strategies such as providing well-packaged, user-friendly program materials at low or no cost and strategic advertisement of the availability of program materials may increase program use and exposure. Furthermore, highlighting the benefits of the program can motivate potential program users.     

Peer Reviewed: Principles to Guide the Development of Population Health Incentives

Improving population health is not simple. Many instruments are available for changing behavior and consequent outcomes. However, the following basic principles should guide development of any incentive arrangement: 1) identify the desired outcome, 2) identify the behavior change that will lead to this outcome, 3) determine the potential effectiveness of the incentive in achieving the behavior change, 4) link a financial incentive directly to this outcome or behavior, 5) identify the possible adverse effects of the incentive, and 6) evaluate and report changes in the behavior or outcome in response to the incentive.A wide range of financial and nonfinancial incentives is available to encourage efficient behaviors and discourage costly and unproductive ones. Evidence for the beneficial effects of incentive programs has been slow to emerge, partly because such evidence must show how behaviors have changed because of the incentive. Nevertheless, the potential for incentive programs in health care seems large, and research should support their design and assess their effect.     

Peer Reviewed: A Weight Loss Intervention for African American Breast Cancer Survivors, 2006

Introduction

Breast cancer survival rates are lower for African American women than for white women. Obesity, high-fat diets, and lack of regular physical activity increase risk for breast cancer recurrence, comorbid conditions, and premature death. Eighty-two percent of African American women are overweight or obese, partly because of unhealthy eating and exercise patterns. Although successful weight loss and lifestyle interventions for breast cancer survivors are documented, none has considered the needs of African American breast cancer survivors. This study assessed the feasibility and impact of Moving Forward, a culturally tailored weight loss program for African American breast cancer survivors.

Methods

The study used a pre-post design with a convenience sample of 23 African American breast cancer survivors. The 6-month intervention was theory-based and incorporated qualitative data from focus groups with the targeted community, urban African American breast cancer survivors. Data on weight, body mass index (BMI), diet, physical activity, social support, and quality of life were collected at baseline and at 6 months.

Results

After the intervention, we noted significant differences in weight, BMI, dietary fat intake, vegetable consumption, vigorous physical activity, and social support.

Conclusion

This is the first published report of Moving Forward, a weight loss intervention designed for African American breast cancer survivors. Although a randomized trial is needed to establish efficacy, the positive results of this intervention suggest that this weight loss intervention may be feasible for African American breast cancer survivors. Lifestyle interventions may reduce the disparities in breast cancer mortality rates.     

Peer Reviewed: Measuring Population Health Outcomes

An ideal population health outcome metric should reflect a population''s dynamic state of physical, mental, and social well-being. Positive health outcomes include being alive; functioning well mentally, physically, and socially; and having a sense of well-being. Negative outcomes include death, loss of function, and lack of well-being. In contrast to these health outcomes, diseases and injuries are intermediate factors that influence the likelihood of achieving a state of health. On the basis of a review of outcomes metrics currently in use and the availability of data for at least some US counties, I recommend the following metrics for population health outcomes: 1) life expectancy from birth, or age-adjusted mortality rate; 2) condition-specific changes in life expectancy, or condition-specific or age-specific mortality rates; and 3) self-reported level of health, functional status, and experiential status. When reported, outcome metrics should present both the overall level of health of a population and the distribution of health among different geographic, economic, and demographic groups in the population.

By far, the most fundamental use of summary measures of population health is to shift the centre of gravity of health policy discourse away from the inputs . . . and throughputs . . . of the health system towards health outcomes for the population. This is not to imply that the resources used and activities undertaken by national or regional health systems are unimportant; quite the contrary. But our understanding of their roles and importance is more appropriate if guided by the real "bottom line," namely their influence on population health. Michael C. Wolfson (1)

     

Peer Reviewed: Feasibility of an Evidence-Based Weight Loss Intervention for a Faith-Based, Rural, African American Population

Background

African Americans and rural residents are disproportionately affected by obesity. Innovative approaches to address obesity that are sensitive to the issues of rural African Americans are needed. Faith-based and community-based participatory approaches show promise for engaging racial/ethnic minorities to change health outcomes, but few faith-based weight loss interventions have used a community-based participatory approach.

Community Context

A faith-based weight loss intervention in the Lower Mississippi Delta arose from a 5-year partnership between academic and community partners representing more than 30 churches and community organizations.

Methods

Community and academic partners translated the 16 core sessions of the Diabetes Prevention Program for rural, church-going African American adults. The feasibility of the lay health advisor–led delivery of the 16-week (January-May 2010), 16-session, adapted intervention was assessed in 26 participants from 3 churches by measuring recruitment, program retention, implementation ease, participant outcomes, and program satisfaction.

Outcome

Twenty-two of 26 participants (85%) provided 16-week follow-up data. Lay health advisors reported that all program components were easy to implement except the self-monitoring component. Participants lost an average of 2.34 kg from baseline to 16-week follow-up, for a mean weight change of −2.7%. Participants reported enjoying the spiritual and group-based aspects of the program and having difficulties with keeping track of foods consumed. The intervention engaged community partners in research, strengthened community-academic partnerships, and built community capacity.

Interpretation

This study demonstrates the feasibility of delivering this adapted intervention by lay leaders through rural churches.     

Peer Reviewed: Multiple Health Behavior Changes in a Cancer Prevention Intervention for Construction Workers, 2001-2003

Introduction

Few multiple behavior change interventions have addressed tobacco use in conjunction with fruit and vegetable consumption, particularly among high-risk blue-collar workers. Tools for Health, a cancer prevention intervention for construction laborers, was effective in achieving behavior change for smoking cessation and fruit and vegetable consumption separately. This study examines whether addressing smoking and fruit and vegetable consumption was successful in achieving positive change for both behaviors. We also explored possible explanations for the relationship between behavior changes in these 2 behavioral domains.

Methods

We retrospectively analyzed data from a randomized controlled trial testing a smoking cessation and fruit and vegetable consumption intervention for construction workers. We used survey data from 300 intervention participants to answer our primary research question: Did participants who reported being smokers at baseline successfully quit smoking and increase their fruit and vegetable consumption by the end of the intervention? We used qualitative data from 16 small group discussions to help interpret these results.

Results

Tools for Health participants achieved substantial levels of smoking cessation and increased their fruit and vegetable consumption, concurrently, during the course of the intervention.

Conclusion

This study provides evidence that pairing smoking cessation with increasing fruit and vegetable consumption can be successful in a multiple behavior change intervention designed for high-risk blue-collar workers. Further, our findings provide potential directions for examining why this pairing might be complementary.