Rural libraries implementing walking groups or walking groups plus civic engagement for walkability in rural communities: a comparative effectiveness trial study protocol

BACKGROUND

Rural residents generally lack adequate physical activity to benefit health and reduce disparities in chronic diseases, such as cardiovascular disease and certain cancers. The Socioecological Model describes physical activity as involving a dynamic and reciprocal interaction between individual, social, and community factors. Community group-based walking programs and civic engagement interventions aimed at enhancing physical activity have been successful in rural communities but have not targeted all three socioecological levels. Public libraries can act as innovative public health partners in rural communities. However, challenges remain because rural libraries often lack the capacity to implement evidence-based health promotion programming. The goals of this study are (1) build the capacity for rural libraries to implement evidence-based health promotion programs, (2) compare changes in physical activity between a group-based walking program and a combined group-based walking and civic engagement program with rural residents, and (3) conduct an implementation evaluation.

METHODS

We will conduct a comparative effectiveness study of a group-based walking (standard approach) versus a group-based walking plus civic engagement program (combined approach) aimed at enhancing walkability to increase physical activity among rural adults. Key mediators between the program effects and change in outcomes will also be identified. Finally, we will evaluate program implementation, conduct a cost effectiveness evaluation, and use a positive deviance analysis to understand experiences of high and low changers on key outcomes. Twenty towns will be matched and randomized to one of the two conditions and our aim is to enroll a total of 350-400 rural residents (15-20 per town). Study outcomes will be assessed at baseline, and 6, 12, and 24 months.

DISCUSSION

This study will build the capacity of rural libraries to implement evidence-based walking programs as well as other health promotion programs in their communities. The study results will answer questions regarding the relative effectiveness and cost effectiveness of two multilevel physical activity interventions targeting rural communities. We will learn what works and how these multilevel interventions can be implemented in rural populations.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT05677906.

Regional delivery in graduate nursing programs for students living in rural communities

Oregon has a lack of primary care providers in rural areas. To address this issue, employers have indicated they plan to hire greater numbers of advanced practice registered nurses (APRNs). Oregon Health & Science University (OHSU) School of Nursing (SoN) responded to this need by developing a statewide delivery model to educate APRN students in their communities. A performance improvement work group including practice faculty, statewide academic leaders, and staff created a project charter with scope of work, timelines, and outcomes with the goal of improving the systems supporting APRN education. An initial distance APRN education delivery model emerged from this effort and was refined over the following year. Strategies were implemented to address identified challenges using small cycles of change. The final model has three main principles: being learner-centered, equitable, and sustainable. The central outcome is graduating students committed to practicing in rural and urban underserved communities to meet workforce needs in Oregon.

Factors impacting implementation of nutrition and physical activity policies in rural schools

BACKGROUND

Rural Latino children have higher rates of obesity compared to non-Latino Whites. Schools are in a unique position to address rural childhood obesity through policies. While evidence exists on factors that promote or impede school-based physical activity (PA) and nutrition policies, only a fraction has been in rural communities. This study seeks to understand 1) the knowledge and perceptions of school nutrition and PA policies and 2) barriers and facilitators to their implementation among rural school stakeholders from Washington State.

METHODS

We conducted 20 semi-structured, in-depth interviews with school stakeholders (e.g., principals and school nutrition directors) from four K-12 school districts in the Lower Yakima Valley of Eastern Washington State. Thematic analysis was conducted using inductive, constant comparison approach to identify themes around knowledge and perceptions of policies and barriers and facilitators of policy implementation.

RESULTS

Three main themes were identified: perceptions and knowledge of school PA and nutrition policies, barriers to policy implementation, and facilitators of policy implementation. The majority of stakeholders were supportive of school-based policies promoting PA and a healthy diet, even when lacking a specific understanding of these policies. Four subthemes were identified as barriers to policy implementation: viewing PA as a low priority, misuse of recess time, funding constraints, and lack of strong leadership. Facilitators of implementation included strong leadership at the district level, creating healthy norms through school-community linkages and pooling community resources to improve nutrition and PA among children.

CONCLUSIONS

Schools provide a unique setting to promote healthy diet and PA behaviors among children and their families. Study findings show that while knowledge of specific nutrition and PA policies may vary, support for such policies were high among rural stakeholders. Study findings can inform policy development and support strategies for policy implementation in rural settings. Future studies may want to examine whether implementation of strategies addressing the barriers and enhancing facilitators lead to success in rural school settings.

Prevalence of Meeting Aerobic, Muscle-Strengthening, and Combined Physical Activity Guidelines During Leisure Time Among Adults, by Rural-Urban Classification and Region - United States, 2020

The healthful effects of physical activity on a multitude of physical and mental health outcomes are well documented (1). Despite promising increases in the percentage of U.S. adults meeting aerobic and muscle-strengthening physical activity guidelines (guidelines)* (1) during leisure time in nearly all demographic and regional subgroups 1998-2018 (2,3), differences by rurality and U.S. Census Bureau region (Northeast, Midwest, South, and West), persist (4). Before 2020, analyses of rural-urban differences were dichotomized into nonmetropolitan (rural) versus metropolitan (urban) areas; however, in 2020 a four-category rural-urban variable^† to classify rural-urban status was included in the National Health Interview Survey (NHIS) public-use dataset. NHIS 2020 data were used to conduct multivariate logistic regression analyses by rural-urban status and U.S. Census Bureau region of the prevalence of meeting the aerobic, muscle-strengthening, and combined aerobic and muscle-strengthening guidelines during leisure time among adults aged ≥18 years, controlling for demographic characteristics. Prevalence of meeting the aerobic, muscle-strengthening, and combined aerobic and muscle-strengthening guidelines was consistently the lowest in Nonmetropolitan counties (38.2%, 21.1%, and 16.1%, respectively) and highest in the West region (52.1%, 35.3%, and 28.5%, respectively). Regardless of rural-urban classification and region, no more than 28% of adults met combined aerobic and muscle-strengthening guidelines. Adults in the most rural category were significantly less likely to meet aerobic, muscle-strengthening, and combined guidelines than were adults in each of the three other categories (adjusted odds ratio [aOR] range = 0.68-0.89). In addition, adults in medium and small metropolitan counties were less likely to meet guidelines than were adults in the two most urban categories (aOR range = 0.85-0.89). Adults in the Northeast, Midwest, and South U.S. Census Bureau regions were less likely to meet guidelines than were adults in the West region (aOR range = 0.75-0.82). These analyses identify geographic disparities in leisure-time physical activity where focused population-level intervention efforts could help reduce or eliminate the consequent disparities in chronic conditions (e.g., cardiovascular diseases) and the resulting mortality (5,6).

Telehealth Competencies: Leveled for Continuous Advanced Practice Nurse Development

BACKGROUND

The COVID-19 pandemic spurred a rapid uptake of telehealth utilization, with advanced practice registered nurses (APRNs) at the forefront of telehealth care delivery. To advance training of nurse practitioners and support curricular development, essential APRN student competencies in telehealth were developed.

PROBLEM

Although telehealth competencies have been developed, little is understood about their evaluation across the curricula. Moving to competency-based nursing education involves leveling broad competencies into subcompetencies, including those for telehealth. Subcompetencies support frequent, multimodal evaluation of student progress across APRN curricula.

APPROACH

Adapting Benner's Novice to Expert Theory, faculty experts in telehealth and graduate nursing education used an iterative process to develop and level subcompetencies aligned with the Four Ps of Telehealth framework.

OUTCOMES

Telehealth subcompetencies were leveled for preclinical and clinical rotations and for readiness for practice.

CONCLUSIONS

The leveled subcompetencies, aligned with the Four Ps of Telehealth framework, will support APRN faculty in diverse programs as they implement competency-based education in telehealth.

Development and validation of self-efficacy and intention measures for spending time in nature

Purpose

The purpose of this study was to develop and evaluate the reliability and validity of self-efficacy and intentions measures for time spent in nature (TSN). TSN is related to improvement in psychological well-being and health, yet most American adults spend very little time in such settings. Theory-based interventions have been effective in increasing physical activity, a related behavior, and may be one mechanism to increase TSN. Self-efficacy and intentions have been shown to be strong predictors of health behaviors and are used across several theories. However, scales to measure these factors have not yet been developed and are needed to facilitate effective interventions.

Methods

TSN self-efficacy and intentions scales were developed using a sequential nine-step procedure: identification of the domain and item generation; content validity; pre-testing of questions; sampling and survey administration; item reduction; extraction of factors; tests of dimensionality; tests of reliability; and tests of validity. The 14-member multidisciplinary, researcher and practitioner investigative team generated 50 unique items for self-efficacy and 24 unique items for intentions. After subjecting items to content validity and pre-testing, item sets were reduced to 21 assessing self-efficacy and nine assessing intentions. A nationwide sample of 2109 adult participants (49.7% female, Mean Age = 58.1; 59.8% White, 18.4% Hispanic, 13.3% Black) answered these items via an on-line survey.

Results

Using split-half measures, principal components analysis indicated a one-factor solution for both scales. The factor structure was upheld in confirmatory factor analyses and had high internal consistency (α = .93 self-efficacy; .91 intentions). The scales were moderately correlated with each other (r = .56, p < .001) and were strongly related to TSN with large effect sizes (eta² > .20).

Conclusions

The study resulted in reliable and valid self-efficacy (14 items) and intentions (8 items) scales that can be used to develop future theory-based interventions to increase TSN and thereby improve population health.

How Type of Practice Ownership Affects Participation with Quality Improvement External Facilitation: Findings from EvidenceNOW

BACKGROUND

Facilitation is an implementation strategy that can help primary care practices improve healthcare quality and build quality improvement (QI) capacity when delivered in a flexible manner by trained professionals. Practice ownership is associated with use of QI. However, little is known about how practices of different ownership participate in external facilitation, and this could inform future initiatives.

OBJECTIVE

Using data from EvidenceNOW, we examined how practice ownership influences participation in external facilitation.

STUDY DESIGN

We used an iterative mixed-methods design.

PARTICIPANTS, APPROACH, AND MEASURES

We collected data from practices on practice characteristics (e.g., location, size, payer mix) and ownership type via surveys and from facilitators on the number of hours, encounters, and months each practice had with a facilitator via facilitation logs. Using multivariable linear regression, we examined the association between facilitation and ownership (n = 1117 practices). We conducted semi-structured interviews with EvidenceNOW leadership (n = 12) and facilitators (n = 51) and observed facilitators in a subset of practices (n = 64); we analyzed this qualitative data for patterns of facilitation.

KEY RESULTS

In the fully adjusted model, differences by ownership were non-significant; FQHCs, however, had significantly less participation in facilitation than clinician-owned practices across two measures (unadjusted difference: - 2.83, p < 0.01 for number of encounters, and - 2.04, p < 0.01 for number of months with encounters). Qualitative data showed that Health System and FQHC ownership influenced types of practices enrolled in EvidenceNOW, and suggested that in these practices lower autonomy and greater complexity compared to clinician-owned ownership influenced facilitation participation patterns.

CONCLUSIONS

Practice ownership shaped how but not how much practices participated in external facilitation. This finding highlights the importance of tailoring facilitation approaches based on ownership-related characteristics in future QI initiatives.

Rural Latino parent and child physical activity patterns: family environment matters

Background

Rural Latino children and adults are less active than urban and non-Latino counterparts. We examined physical activity (PA) patterns of rural Latino children and their parents, and explored parental beliefs about and reported barriers of Latino family physical activity. Latino families in a rural area in eastern Washington state, with children in grades 3–5 were included.

Methods

We used mixed methods. Children (n = 27) and parents (n = 25) wore an accelerometer for 5 days; parents (n = 31) participated in a semi-structured interview and completed a demographic survey. Parent and child activity levels were compared using paired t-tests; interviews were analyzed with qualitative content analysis.

Results

Although 100% children and 46% parents met physical activity guidelines, parents and children spent most of the day in sedentary behaviors. Parent-reported PA barriers included their long work hours, lack of transportation, and their child’s screen-time.

Conclusion

Addressing barriers and reducing sedentary time could increase PA of rural Latino families.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12889-021-12085-w.

What Sets Physically Active Rural Communities Apart from Less Active Ones? A Comparative Case Study of Three US Counties

BACKGROUND

Rural US communities experience health disparities, including a lower prevalence of physical activity (PA). However, "Positive Deviants"-rural communities with greater PA than their peers-exist. The purpose of this study was to identify the factors that help create physically active rural US communities.

METHODS

Stakeholder interviews, on-site intercept interviews, and in-person observations were used to form a comparative case study of two rural counties with high PA prevalence (HPAs) and one with low PA prevalence (LPA) from a southern US state, selected based on rurality and adult PA prevalence. Interview transcripts were inductively coded by three readers, resulting in a thematic structure that aligned with a Community Capital Framework, which was then used for deductive coding and analysis.

RESULTS

Fifteen stakeholder interviews, nine intercept interviews, and on-site observations were conducted. Human and Organizational Capital differed between the HPAs and LPA, manifesting as Social, Built, Financial, and Political Capital differences and a possible "spiraling-up" or cyclical effect through increasing PA and health (Human Capital), highlighting a potential causal model for future study.

CONCLUSIONS

Multi-organizational PA coalitions may hold promise for rural PA by directly influencing Human and Organizational Capital in the short term and the other forms of capital in the long term.

The Effects of Play Streets on Social and Community Connectedness in Rural Communities

Promoting physical activity (PA) is a long-standing public health initiative to improve overall health and wellbeing. Innovative strategies such as Play Streets, temporary activation of public spaces to provide safe places for active play, are being adopted in urban and rural communities to increase PA among children. As part of these strategies, aspects of social and community connectedness may be strengthened. This study analyzes focus groups and interviews from rural Play Street implementation team members (n = 14) as well as adults (n = 7) and children (n = 25) who attended Play Streets hosted in rural North Carolina, Maryland, Oklahoma, and Texas to better understand the added benefits of Play Streets in community connectedness. Overall, elements of social support and social cohesion are mentioned most frequently with instrumental and conditional support; however, concepts of social capital, collective-efficacy, and social identification are also presented. Participants expressed that Play Streets provided more than just PA; they provided opportunities to access and share resources, build perceptions of safety and trust in the community, and develop relationships with others. Fostering community connection through Play Streets may reduce health inequities in rural communities by building community resilience. Community-based PA programming that enhance and capitalize on community connectedness could be effective ways to improving the overall health and wellbeing of residents.

Environmental Factors Associated with Physical Activity in Rural U.S. Counties

Background: Rural U.S. adults’ prevalence of meeting physical activity (PA) guidelines is lower than urban adults, yet rural-urban differences in environmental influences of adults’ PA are largely unknown. The study’s objective was to identify rural-urban variations in environmental factors associated with the prevalence of adults meeting PA guidelines. Methods: County-level data for non-frontier counties (n = 2697) were used. A five-category rurality variable was created using the percentage of a county’s population living in a rural area. Factor scores from Factor Analyses (FA) were used in subsequent Multiple Linear Regression (MLR) analyses stratified by rurality to identify associations between environmental factor scores and the prevalence of males and females meeting PA guidelines. Results: FA revealed a 13-variable, four-factor structure of natural, social, recreation, and transportation environments. MLR revealed that natural, social, and recreation environments were associated with PA for males and females, with variation by sex for social environment. The natural environment was associated with PA in all but urban counties; the recreation environment was associated with PA in the urban counties and the two most rural counties. Conclusions: Variations across the rural-urban continuum in environmental factors associated with adults’ PA, highlight the uniqueness of rural PA and the need to further study what succeeds in creating active rural places.

Cultural And Structural Features Of Zero-Burnout Primary Care Practices

Although much attention has been focused on individual-level drivers of burnout in primary care settings, examining the structural and cultural factors of practice environments with no burnout could identify solutions. In this cross-sectional analysis of survey data from 715 small-to-medium-size primary care practices in the United States participating in the Agency for Healthcare Research and Quality's EvidenceNOW initiative, we found that zero-burnout practices had higher levels of psychological safety and adaptive reserve, a measure of practice capacity for learning and development. Compared with high-burnout practices, zero-burnout practices also reported using more quality improvement strategies, more commonly were solo and clinician owned, and less commonly had participated in accountable care organizations or other demonstration projects. Efforts to prevent burnout in primary care may benefit from focusing on enhancing organization and practice culture, including promoting leadership development and fostering practice agency.

An Evidence-Based Walking Program in Oregon Communities: Step It Up! Survivors

Physical activity can help mitigate the long-term symptoms and side effects of cancer and its treatment, but most cancer survivors are not active enough to achieve these benefits. An evidence-based strategy to promote physical activity among adults is a community group–based walking program. However, many evidence-based programs do not achieve intended population health outcomes because of the challenges of real-world implementation. We used the Interactive Systems Framework for Dissemination and Implementation to conceptualize implementation of a capacity-building intervention to support delivery of a community group–based walking program. We adapted an evidence-based guide for community group–based walking programs for cancer survivors and their support network. We provided a capacity-building intervention (technical assistance and small-grant funding) and evaluated this implementation intervention. We assessed effectiveness of the intervention by measuring adoption, acceptability, appropriateness, feasibility, fidelity, implementation costs, and penetration through monthly progress reports, site visit observations, interviews, and a final report. Eight organizations received a small grant and technical assistance and implemented Step It Up! Survivors (SIUS). SIUS helped cancer survivors increase their physical activity, establish social connections, and be part of a supportive environment. Despite receiving monthly technical assistance, some grantees experienced challenges in recruiting participants, developing community partnerships, and adhering to the prescribed implementation plan. Implementation facilitators included community partners and specific components (eg, incentives for participants, webinars). Organizations needed different amounts and types of assistance with adaptation and implementation. Overall fidelity to SIUS ranged from 64% to 88%. Some integrated SIUS within existing organizational programming for sustainability. The provision of funding and technical assistance was a successful implementation intervention. Our results suggest a need to better tailor technical assistance while organizations are in the process of adapting, implementing, and sustaining an evidence-based program in their local communities.

Attitudes and Beliefs of Older Female Breast Cancer Survivors and Providers About Exercise in Cancer Care

OBJECTIVES

To understand breast cancer survivors' and providers' attitudes and beliefs regarding exercise counseling and structured exercise programs within cancer care.

SAMPLE & SETTING

61 female breast cancer survivors and 11 breast cancer providers from a university cancer center in the Pacific Northwest.

METHODS & VARIABLES

Survivors completed anonymous self-report surveys, and providers participated in semistructured interviews. Survey data were analyzed using descriptive statistics, and interview transcripts were analyzed using qualitative content analysis.

RESULTS

Breast cancer survivors and providers believed that including exercise counseling within cancer care was important. More than half of the survivors reported that they would attend structured exercise classes; a majority of providers thought cancer centers should offer exercise programs.

IMPLICATIONS FOR NURSING

Nurses could facilitate exercise counseling within cancer care and advocate for clinic-based exercise programs.

Financial hardship among rural cancer survivors: An analysis of the Medical Expenditure Panel Survey

Some cancer survivors report spending 20% of their annual income on medical care. Undue financial burden that patients face related to the cost of care is referred to as financial hardship, which may be more prevalent among rural cancer survivors. This study examined contrasts in financial hardship among 1419 rural and urban cancer survivors using the 2011 Medical Expenditure Panel Survey supplement - The Effects of Cancer and Its Treatment on Finances. We combined four questions, creating a measure of material financial hardship, and examined one question on financial worry. We conducted multivariable logistic regression analyses, which produced odds ratios (OR) for factors associated with financial hardship and worry, and then generated average adjusted predicted probabilities. We focused on rural and urban differences classified by metropolitan statistical area (MSA) designation, controlling for age, education, race, marital status, health insurance, family income, and time since last cancer treatment. More rural cancer survivors reported financial hardship than urban survivors (23.9% versus 17.1%). However, our adjusted models revealed no significant impact of survivors' MSA designation on financial hardship or worry. Average adjusted predicted probabilities of financial hardship were 18.6% for urban survivors (Confidence Interval [CI]: 11.9%-27.5%) and 24.2% for rural survivors (CI: 15.0%-36.2%). For financial worry, average adjusted predicted probabilities were 19.9% for urban survivors (CI: 12.0%-31.0%) and 18.8% for rural survivors (CI: 12.1%-28.0%). Improving patient-provider communication through decision aids and/or patient navigators may be helpful to reduce financial hardship and worry regardless of rural-urban status.

Sedentary Behaviors in Today's Youth: Approaches to the Prevention and Management of Childhood Obesity: A Scientific Statement From the American Heart Association

This scientific statement is about sedentary behavior and its relationship to obesity and other cardiometabolic outcomes in youth. A deleterious effect of sedentary behavior on cardiometabolic health is most notable for screen-based behaviors and adiposity; however, this relation is less apparent for other cardiometabolic outcomes or when sedentary time is measured with objective movement counters or position monitors. Increasing trends of screen time are concerning; the portability of screen-based devices and abundant access to unlimited programming and online content may be leading to new patterns of consumption that are exposing youth to multiple pathways harmful to cardiometabolic health. This American Heart Association scientific statement provides an updated perspective on sedentary behaviors specific to modern youth and their impact on cardiometabolic health and obesity. As we reflect on implications for practice, research, and policy, what emerges is the importance of understanding the context in which sedentary behaviors occur. There is also a need to capture the nature of sedentary behavior more accurately, both quantitatively and qualitatively, especially with respect to recreational screen-based devices. Further evidence is required to better inform public health interventions and to establish detailed quantitative guidelines on specific sedentary behaviors in youth. In the meantime, we suggest that televisions and other recreational screen-based devices be removed from bedrooms and absent during meal times. Daily device-free social interactions and outdoor play should be encouraged. In addition, parents/guardians should be supported to devise and enforce appropriate screen time regulations and to model healthy screen-based behaviors.

Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory

BACKGROUND

The use of implementation strategies is an active and purposive approach to translate research findings into routine clinical care. The Expert Recommendations for Implementing Change (ERIC) identified and defined discrete implementation strategies, and Proctor and colleagues have made recommendations for specifying operationalization of each strategy. We use empirical data to test how the ERIC taxonomy applies to a large dissemination and implementation initiative aimed at taking cardiac prevention to scale in primary care practice.

METHODS

EvidenceNOW is an Agency for Healthcare Research and Quality initiative that funded seven cooperatives across seven regions in the USA. Cooperatives implemented multi-component interventions to improve heart health and build quality improvement capacity, and used a range of implementation strategies to foster practice change. We used ERIC to identify cooperatives' implementation strategies and specified the actor, action, target, dose, temporality, justification, and expected outcome for each. We mapped and compiled a matrix of the specified ERIC strategies across the cooperatives, and used consensus to resolve mapping differences. We then grouped implementation strategies by outcomes and justifications, which led to insights regarding the use of and linkages between ERIC strategies in real-world scale-up efforts.

RESULTS

Thirty-three ERIC strategies were used by cooperatives. We identified a range of revisions to the ERIC taxonomy to improve the practical application of these strategies. These proposed changes include revisions to four strategy names and 12 definitions. We suggest adding three new strategies because they encapsulate distinct actions that were not described in the existing ERIC taxonomy. In addition, we organized ERIC implementation strategies into four functional groupings based on the way we observed them being applied in practice. These groupings show how ERIC strategies are, out of necessity, interconnected, to achieve the work involved in rapidly taking evidence to scale.

CONCLUSIONS

Findings of our work suggest revisions to the ERIC implementation strategies to reflect their utilization in real-work dissemination and implementation efforts. The functional groupings of the ERIC implementation strategies that emerged from on-the-ground implementers will help guide others in choosing among and linking multiple implementation strategies when planning small- and large-scale implementation efforts.

TRIAL REGISTRATION

Registered as Observational Study at www.clinicaltrials.gov ( NCT02560428 ).

Specifying and comparing implementation strategies across seven large implementation interventions: a practical application of theory

BACKGROUND

The use of implementation strategies is an active and purposive approach to translate research findings into routine clinical care. The Expert Recommendations for Implementing Change (ERIC) identified and defined discrete implementation strategies, and Proctor and colleagues have made recommendations for specifying operationalization of each strategy. We use empirical data to test how the ERIC taxonomy applies to a large dissemination and implementation initiative aimed at taking cardiac prevention to scale in primary care practice.

METHODS

EvidenceNOW is an Agency for Healthcare Research and Quality initiative that funded seven cooperatives across seven regions in the USA. Cooperatives implemented multi-component interventions to improve heart health and build quality improvement capacity, and used a range of implementation strategies to foster practice change. We used ERIC to identify cooperatives' implementation strategies and specified the actor, action, target, dose, temporality, justification, and expected outcome for each. We mapped and compiled a matrix of the specified ERIC strategies across the cooperatives, and used consensus to resolve mapping differences. We then grouped implementation strategies by outcomes and justifications, which led to insights regarding the use of and linkages between ERIC strategies in real-world scale-up efforts.

RESULTS

Thirty-three ERIC strategies were used by cooperatives. We identified a range of revisions to the ERIC taxonomy to improve the practical application of these strategies. These proposed changes include revisions to four strategy names and 12 definitions. We suggest adding three new strategies because they encapsulate distinct actions that were not described in the existing ERIC taxonomy. In addition, we organized ERIC implementation strategies into four functional groupings based on the way we observed them being applied in practice. These groupings show how ERIC strategies are, out of necessity, interconnected, to achieve the work involved in rapidly taking evidence to scale.

CONCLUSIONS

Findings of our work suggest revisions to the ERIC implementation strategies to reflect their utilization in real-work dissemination and implementation efforts. The functional groupings of the ERIC implementation strategies that emerged from on-the-ground implementers will help guide others in choosing among and linking multiple implementation strategies when planning small- and large-scale implementation efforts.

TRIAL REGISTRATION

Registered as Observational Study at www.clinicaltrials.gov ( NCT02560428 ).

Mujeres Fuertes y Corazones Saludables, a Culturally Tailored Physical Activity and Nutrition Program for Rural Latinas: Findings from a Pilot Study

In the United States, Latino adults, compared with non-Hispanic white adults, are less likely to meet physical activity and dietary recommendations, and have higher rates of obesity. There is an urgent need for culturally adapted health promotion programs that meet the needs of the growing Latino population in the United States. We systematically adapted StrongWomen-Healthy Hearts, an evidence-based physical activity and nutrition program, for rural Latinas. This paper reports results from a pilot study of the adapted program. We used mixed methods to assess the feasibility and efficacy of the adapted program, Mujeres Fuertes y Corazones Saludables, in a nonprofit community organization serving rural Latinos. The intervention consisted of sixty-minute classes held twice weekly for 12 weeks and included 30 minutes of physical activity and 30 minutes of nutrition education. To assess efficacy, we used a one-group, pre⁻post design with overweight/obese, sedentary, middle-aged or older, Spanish-speaking rural Latinas (n = 15). Outcome measures included weight, height, body mass index (BMI), waist circumference, cardiorespiratory fitness, physical activity, dietary behavior, and self-efficacy for diet and physical activity. Process outcomes included attendance, end of class surveys, mid-program evaluation survey, and a post-program focus group. We calculated means and standard deviations, paproired t-tests, and Cohen's D effect size. Qualitative data were analyzed using qualitative description. Significant changes pre- to post-program included weight (-1.5 kg; p = 0.009), BMI (-0.6; p = 0.005), waist circumference (-3.0 cm; p = 0.008), 6-minute walk test (69.7 m; p < 0.001), frequency of sugar-added drink consumption (-0.7 servings; p = 0.008), fruit and vegetable intake (1.3 servings; p = 0.035), and physical activity self-efficacy (0.9 points; p = 0.022). Participants found the program motivating and enjoyable, and on average participants attended 62% of classes and fidelity was maintained. This pilot study suggests that this culturally adapted physical activity and nutrition program for rural Latinas shows promise in improving physical activity, diet, and obesity.

Food availability and food access in rural agricultural communities: use of mixed methods

Background

Hispanics bear some of the highest burden of the obesity epidemic and the disparities gap is bigger among Hispanics in rural communities. This mixed methods study examined the objective and subjective assessment of food availability and food access in four rural, agricultural, and predominantly Hispanic communities.

Methods

In this convergent parallel mixed methods study, we used the Nutrition Environment Measures Survey (NEMS) of Food Stores and Restaurants to objectively assess 57 food stores and 69 restaurants in four rural agricultural communities in Washington State. To complement the objective assessment findings, we conducted semi-structured interviews with 32 community residents. The data were collected from 2013 to 2014. Frequencies and means were calculated for quantitative data and content analysis conducted for interview data.

Results

Participants (n = 32) had a mean age of 35.6 (SD 6.2) years, were mostly women, uninsured, low income, and had less than a high school education. Grocery and convenience stores had low NEMS composite scores indicating low overall availability of food items, low quality, and high food prices. Composite scores for sit-down restaurants, fast casual restaurants, and fast-food restaurants were similarly low in all four towns indicating limited availability of healthier options. Semi-structured interviews revealed participants perceived high availability and accessibility of quality fresh produce. Most participants reported eating out regularly several times a week, frequenting restaurant chains that serve buffets or fast foods, and allowing children to make decisions regarding their own food choices.

Conclusions

Community members’ perception of food availability and food access may be different from the objective assessment of food environment. This information can be used to inform community-wide interventions to address food environment in these rural communities.

Mujeres Fuertes y Corazones Saludables: adaptation of the StrongWomen -healthy hearts program for rural Latinas using an intervention mapping approach

Objective

To describe our use of intervention mapping as a systematic method to adapt an evidence-based physical activity and nutrition program to reflect the needs of rural Latinas.

Methods

An intervention mapping process involving six steps guided the adaptation of an evidence based physical activity and nutrition program, using a community-based participatory research approach. We partnered with a community advisory board of rural Latinas throughout the adaptation process.

Results

A needs assessment and logic models were used to ascertain which program was the best fit for adaptation. Once identified, we collaborated with one of the developers of the original program (StrongWomen - Healthy Hearts) during the adaptation process. First, essential theoretical methods and program elements were identified, and additional elements were added or adapted. Next, we reviewed and made changes to reflect the community and cultural context of the practical applications, intervention strategies, program curriculum, materials, and participant information. Finally, we planned for the implementation and evaluation of the adapted program, Mujeres Fuertes y Corazones Saludables, within the context of the rural community. A pilot study will be conducted with overweight, sedentary, middle-aged, Spanish-speaking Latinas. Outcome measures will assess change in weight, physical fitness, physical activity, and nutrition behavior.

Conclusions

The intervention mapping process was feasible and provided a systematic approach to balance fit and fidelity in the adaptation of an evidence-based program. Collaboration with community members ensured that the components of the curriculum that were adapted were culturally appropriate and relevant within the local community context.

Driven to Support: Individual- and County-Level Factors Associated With Public Support for Active Transportation Policies

PURPOSE

To assess predictors of stated support for policies promoting physically active transportation.

DESIGN

Cross-sectional.

SETTING

US counties selected on county-level physical activity and obesity health status.

PARTICIPANTS

Participants completing random-digit dialed telephone survey (n = 906).

MEASURES

Survey measures assessed stated support for 5 policies to promote physically active transportation, access to active transportation facilities, and time spent in a car. County-level estimates included household car dependence and funding for bicycle-pedestrian projects.

ANALYSIS

Multivariable generalized linear mixed models using binary distribution and logit link, accounting for clustering within county.

RESULTS

Respondents supported policies for accommodating bicyclists and pedestrians through street improvements (89%), school active transportation programs (75%), employer-funded active commuting incentives (67%), and allocation of public funding (68%) and tax support (56%) for building and maintaining public transit. Residents spending >2 h/d (vs <0.7 hours) in cars were more likely to support street (odds ratio [OR]: 1.87; confidence interval [CI]: 1.09-3.22) and public transit (OR: 1.85; CI: 1.24-2.77) improvements. Residents in counties investing >$1.6 million in bicycle and pedestrian improvements expressed greater support for funding (OR: 1.71; CI: 1.04-2.83) and tax increases (OR: 1.73; CI: 1.08-2.75) for transit improvements compared to those with lower prior investments (<$276 100).

CONCLUSION

Support for policies to enable active transportation is higher where relevant investments in active transportation infrastructure are large (>$1.6 M), public transit is nearby, and respondents drive >2 h/d.

Places where children are active: A longitudinal examination of children's physical activity

Using two-year longitudinal data, we examined locations where children spent time and were active, whether location patterns were stable, and relationships between spending time in their home neighborhood and moderate to vigorous physical activity (MVPA). At two time points (2007-2009 and 2009-2011), children living in the metropolitans areas of either San Diego, CA or Seattle, WA wore an accelerometer, and parents recorded their child's locations for seven days. Across two years, global average proportion of time spent in each location was stable, but total time and proportion of time in each location spent in MVPA decreased significantly across all locations. Children spent the largest proportion of time in MVPA in their home neighborhood at both time points, although they spent little time in their home neighborhood.

Sedentary Behavior and Cardiovascular Morbidity and Mortality: A Science Advisory From the American Heart Association

Epidemiological evidence is accumulating that indicates greater time spent in sedentary behavior is associated with all-cause and cardiovascular morbidity and mortality in adults such that some countries have disseminated broad guidelines that recommend minimizing sedentary behaviors. Research examining the possible deleterious consequences of excess sedentary behavior is rapidly evolving, with the epidemiology-based literature ahead of potential biological mechanisms that might explain the observed associations. This American Heart Association science advisory reviews the current evidence on sedentary behavior in terms of assessment methods, population prevalence, determinants, associations with cardiovascular disease incidence and mortality, potential underlying mechanisms, and interventions. Recommendations for future research on this emerging cardiovascular health topic are included. Further evidence is required to better inform public health interventions and future quantitative guidelines on sedentary behavior and cardiovascular health outcomes.

Physical Activity-Related Policy and Environmental Strategies to Prevent Obesity in Rural Communities: A Systematic Review of the Literature, 2002-2013

INTRODUCTION

Health disparities exist between rural and urban residents; in particular, rural residents have higher rates of chronic diseases and obesity. Evidence supports the effectiveness of policy and environmental strategies to prevent obesity and promote health equity. In 2009, the Centers for Disease Control and Prevention recommended 24 policy and environmental strategies for use by local communities: the Common Community Measures for Obesity Prevention (COCOMO); 12 strategies focus on physical activity. This review was conducted to synthesize evidence on the implementation, relevance, and effectiveness of physical activity-related policy and environmental strategies for obesity prevention in rural communities.

METHODS

A literature search was conducted in PubMed, PsycINFO, Web of Science, CINHAL, and PAIS databases for articles published from 2002 through May 2013 that reported findings from physical activity-related policy or environmental interventions conducted in the United States or Canada. Each article was extracted independently by 2 researchers.

RESULTS

Of 2,002 articles, 30 articles representing 26 distinct studies met inclusion criteria. Schools were the most common setting (n = 18 studies). COCOMO strategies were applied in rural communities in 22 studies; the 2 most common COCOMO strategies were "enhance infrastructure supporting walking" (n = 11) and "increase opportunities for extracurricular physical activity" (n = 9). Most studies (n = 21) applied at least one of 8 non-COCOMO strategies; the most common was increasing physical activity opportunities at school outside of physical education (n = 8). Only 14 studies measured or reported physical activity outcomes (10 studies solely used self-report); 10 reported positive changes.

CONCLUSION

Seven of the 12 COCOMO physical activity-related strategies were successfully implemented in 2 or more studies, suggesting that these 7 strategies are relevant in rural communities and the other 5 might be less applicable in rural communities. Further research using robust study designs and measurement is needed to better ascertain implementation success and effectiveness of COCOMO and non-COCOMO strategies in rural communities.

Active living environment assessments in four rural Latino communities

Objective

Latinos and rural residents are less active and have a greater prevalence of overweight/obesity compared with their non-Latino white and urban counterparts. The objective of this study was to assess the active living environment in four rural, predominantly Latino communities.

Methods

Assessments were taken using the Rural Active Living Assessment (RALA) in four rural predominantly Latino communities in Central Washington from September–November 2013. Street Segment Assessments of town center, thoroughfare, neighborhood and school zones were assessed for features related to walkability. Physical activity amenities, programs and policies in each town were assessed. Scores were generated for amenities, programs and policies. Data were analyzed with descriptive statistics and logistic regression.

Results

A total of 103 segments were assessed. Sidewalks in good condition were present in 32% of segments and shoulders in 44% of segments. Half of street segments were rated as walkable. Parks and playgrounds were available; however, half of these were rated in poor condition. All four districts offered after school physical activity programming but only two had a late bus option.

Conclusions

These four rural towns have some policies, programming and infrastructure in place that support active living. The information from the RALA can be used to inform program and policy development to enhance physical activity in these rural communities.

•

Parks and playgrounds were available in all four rural communities.

•

All four school districts allowed public access to facilities after school hours.

•

Less than half of street segments had sidewalks or shoulders.

•

Half of street segments were rated as walkable.

Does neighborhood walkability moderate the effects of intrapersonal characteristics on amount of walking in post-menopausal women?

This study identifies factors associated with walking among postmenopausal women and tests whether neighborhood walkability moderates the influence of intrapersonal factors on walking. We used data from the Women's Health Initiative Seattle Center and linear regression models to estimate associations and interactions. Being white and healthy, having a high school education or beyond and greater non-walking exercise were significantly associated with more walking. Neighborhood walkability was not independently associated with greater walking, nor did it moderate influence of intrapersonal factors on walking. Specifying types of walking (e.g., for transportation) can elucidate the relationships among intrapersonal factors, the built environment, and walking.

Intrapersonal, behavioral, and environmental factors associated with meeting recommended physical activity among rural Latino youth

This study aimed to identify intrapersonal, behavioral, and environmental factors associated with engaging in recommended levels of physical activity among rural Latino middle school youth. Data were from an anonymous survey of 773 Latino youth (51% female) about level of and barriers and motivators to physical activity, risk behaviors, and park use. Logistic regression models identified factors correlated with meeting recommended levels of physical activity (5 days or more 3 60 min/day). Thirty-four percent of girls and 41% of boys reported meeting this physical activity recommendation. Participation in an organized after school activity (p < .001) and in physical education (PE) classes 5 days a week (p < .001) were strongly associated with meeting recommended physical activity level. Making PE available 5 days a week and creating opportunities for organized after school physical activity programs may increase the number of rural Latino middle school youth who meet recommended physical activity level.

A compassionate autonomy alternative to speciesism

Many people in the animal welfare community have argued that the use of nonhuman animals in medical research is necessarily based on speciesism, an unjustified prejudice based on species membership. As such it is morally akin to racism and sexism. This is misguided. The combined capacities for autonomy and sentience with the obligations derived from relations support a morally justifiable rationale for using some nonhuman animals in order to limit the risk of harm to humans. There may be a few cases where it is morally better to use a never sentient human than a sentient animal, but these cases are few and would not fulfill the current need for research subjects. The use of nonautonomous animals instead of humans in risky research can be based on solid moral ground. It is not necessarily speciesism.

Effects of environmental noise on computer-derived voice estimates from female speakers

The purpose of this study was to examine the influence of noise on voice profile statistics from female samples. Six young adult females served as subjects. Five had normal voices; one had a pathological voice with accompanying bilateral vocal nodules. Each female subject was required to match a generated 235 Hz tone (+/- 2 Hz) while maintaining a constant output level of 70 dB SPL (+/- 5 dB). Data collected from a previous study involving a normal male subject were included for comparative purposes. Noise was generated from a personal computer fan which had a strong center frequency component at 235 Hz. Six different A-weighted signal-to-noise [S/N(A)] conditions were created, ranging in 5 dB increments from 25 to 0 dB. Results revealed that fundamental frequency was reasonably resistant to the effects of noise and to the effects of the noisy (pathological) voice signal. Jitter and shimmer estimates generally increased as noise floors elevated. The greatest amount of measurement error was found for the pathological female voice when captured in the presence of environmental noise. Findings are discussed relative to clinical issues surrounding measurement error.

Measures of language proficiency as predictors of behavioral difficulties, social and cognitive development in 2-year-old children

An exploratory study of the relation of language proficiency, behavioral difficulties, and various areas of development was conducted with 64 children ranging from 24 to 29 months of age (M = 25.7 mo.). Data were obtained through language sampling, direct developmental assessment, and maternal reports of children's development and behavior. While scores on measures of expressive language abilities were moderately predictive of scores on measures of behavior problems, a stronger association was found between indices of delayed speech and lower scores on both social and cognitive development. The results point to the centrality of language development to other developmental and behavioral milestones. Further, findings support the importance of identifying late-talking children at an early age so that remedial help may be considered.

Accuracy of jitter estimates using different filter settings on Visi-Pitch: a preliminary report

Preliminary findings are presented regarding Visi-Pitch settings in relation to automatically derived perturbation values (jitter). Jitter values were estimated from sustained phonation of /a/ at each of four filter settings for three subjects using Visi-Pitch. Data were compared to values obtained by hand measuring the same signals and employing Koike's formula. Results indicated that the magnitude of difference between jitter estimated by Visi-Pitch and hand measurement was small. Findings support the use of the manufacturer's recommended filter settings as opposed to alternative settings suggested by Karnell.

Psychometric and descriptive perspectives of illness impact over the life span

This article describes the development of an instrument that quantifies illness over the course of life. The sample was comprised of 308 women, aged 50 to 70, who were alumnae of a master's program in nursing. Each submitted information concerning illness experienced during each decade of life. Each time period was then rated multidimensionally (Duration, Discomfort, Interference, Threat to Life) to reflect the impact of the various conditions and the means by decade (Decade Impact) were computed. In general, after the first two decades, magnitude of ratings increased with age, indicating greater disease impact. Interrater reliability and internal consistency reliability of the scale were high. Evidence for construct validity included substantial differences between those with and without specific illness conditions, as well as correlations with hospitalization history and health self-ratings. In cluster analysis of patterns across decades, five distinct patterns emerged into which subjects were grouped.