Examining local smoke-free coalitions in Armenia and Georgia: context and outcomes of a matched-pairs community-randomised controlled trial.

INTRODUCTION: Local coalitions can advance public health initiatives such as smoke-free air but have not been widely used or well-studied in low-income and middle-income countries. METHODS: We conducted a matched-pairs community-randomised controlled trial in 28 communities in Armenia and Georgia (N=14/country) in which we helped establish local coalitions in 2019 and provided training and technical assistance for coalition activity promoting smoke-free policy development and enforcement (2019-2021). Surveys of ~1450 households (Fall 2018, May-June 2022) were conducted to evaluate coalition impact on smoke-free policy support, smoke-free home adoption, secondhand smoke exposure (SHSe), and coalition awareness and activity exposure, using multivariable mixed modelling. RESULTS: Bivariate analyses indicated that, at follow-up versus baseline, both conditions reported greater smoke-free home rates (53.6% vs 38.5%) and fewer days of SHSe on average (~11 vs ~12 days), and that intervention versus control condition communities reported greater coalition awareness (24.3% vs 12.2%) and activity exposure (71.2% vs 64.5%). Multivariable modelling indicated that intervention (vs control) communities reported greater rates of complete smoke-free homes (adjusted Odds Ratio [aOR] 1.55, 95% confiedence interval [CI] 1.11 to 2.18, p=0.011) and coalition awareness (aOR 2.89, 95% CI 1.44 to 8.05, p=0.043) at follow-up. However, there were no intervention effects on policy support, SHSe or community-based activity exposure. CONCLUSIONS: Findings must be considered alongside several sociopolitical factors during the study, including national smoke-free policies implementation (Georgia, 2018; Armenia, 2022), these countries' participation in an international tobacco legislation initiative, the COVID-19 pandemic and regional/local war). The intervention effect on smoke-free homes is critical, as smoke-free policy implementation provides opportunities to accelerate smoke-free home adoption via local coalitions. TRIAL REGISTRATION NUMBER: NCT03447912.

A structural equation model of CFIR inner and outer setting constructs, organization characteristics, and national DPP enrollment.

BACKGROUND: The National Diabetes Prevention Program (DPP) has made great strides in increasing accessibility to its year-long, evidence-based lifestyle change program, with around 3000 organizations having delivered the program. This large dissemination effort offers a unique opportunity to identify organization-level factors associated with program implementation and reach (enrollment) across diverse settings. The purpose of this study was to quantitatively examine the relationships among Consolidated Framework for Implementation Research (CFIR) Inner Setting and Outer Setting constructs and the implementation outcome of reach. METHODS: This study analyzed data from a 2021 cross-sectional online survey with 586 National DPP Staff (lifestyle coaches, master trainers, program coordinators) with information about their organization, implementation outcomes, and responses to quantitative CFIR Inner Setting and Outer Setting construct items. Structural equation modeling was used to test a hypothesized path model with Inner and Outer Setting variables to explore direct and indirect pathways to enrollment. RESULTS: The CFIR items had good internal consistency and indicated areas of implementation strength and weakness. Eight variables included as part of the CFIR structural characteristics and one organization characteristic variable had significant direct relationships with enrollment. The length of delivery, number of lifestyle coaches, number of full-time staff, large organization size, and organizations delivering in rural, suburban, and/or urban settings all had positive significant direct relationships with enrollment, while academic organizations and organizations with only non-White participants enrolled in their National DPP lifestyle change programs had a negative association with enrollment. CONCLUSIONS: Participant reach is an important implementation outcome for the National DPP and vital to making population-level decreases in diabetes incidence in the USA. Our findings suggest that to facilitate enrollment, program implementers should focus on organizational structural characteristics such as staffing. Strengths of this study include the use of adapted and newly developed quantitative CFIR measures and structural equation modeling. Health prevention programs can use the methods and findings from this study to further understand and inform the impact of organization factors on implementation outcomes.

Patterns of Sustainability Capacity Among Organizations That Deliver the National Diabetes Prevention Program: A Latent Profile Analysis.

INTRODUCTION: Since the launch of the National Diabetes Prevention Program (DPP) in 2010, more than 3,000 organizations have registered with the Centers for Disease and Control and Prevention to deliver the program; today, however, only approximately 2,000 organizations are registered, indicating challenges with sustainability. We used the Program Sustainability Assessment Tool (PSAT) to explore patterns of sustainability capacity among National DPP delivery organizations. METHODS: We used data from a cross-sectional online survey conducted in August and September 2021 of staff members (N = 440) at National DPP delivery organizations. We conducted a latent profile analysis to identify latent subpopulations on the basis of respondent PSAT domain scores. Regression analyses were used to estimate associations between derived latent classes, PSAT scores, and respondent characteristics. RESULTS: The 4-class model included 4 groups of capacity for program sustainability, ranging from low to high: low (class 1) with 8.0% of the sample, medium-low (class 2) with 22.0%, medium-high (class 3) with 41.6%, and high (class 4) with 28.4%. Program evaluation (mean score = 5.1 [SD = 1.4]) and adaptation (mean score = 5.3 [SD = 1.3]) were the domains with the highest scores, while funding stability (mean score = 4.0 [SD = 1.6]) and Partnerships (mean score = 4.0 [SD = 1.7]) had the lowest scores. In our sample of National DPP delivery organizations, most reported relatively high capacity for program sustainability, and key indicators associated with sustainability capacity were virtual delivery, location of delivery, funding sources, and organization type. DISCUSSION: Similar to sustainability capacity findings from other PSAT studies, our study found that funding stability and partnerships are areas to strengthen. This insight is useful in sustainability planning at organizational and national levels across multiple programs.

Associations Between Pro/Anti-Tobacco Media and Messaging Exposure and Knowledge and Support of Smoke-Free Policy Among Adults in Armenia and Georgia.

CONTEXT: Despite high smoking rates, Armenia and Georgia recently adopted smoke-free policies (2022 and 2018). OBJECTIVE: We examined associations between exposure to pro-tobacco media (news opposing smoke-free policies; cigarette, e-cigarette, heated tobacco product [HTP] advertisements) and anti-tobacco media (media, community-based action) and (1) knowledge that the policies applied to alternative tobacco products (ATPs), and (2) support for the policies applying to ATPs and various settings. DESIGN: We analyzed 2022 survey data. SETTING: Data were from 28 communities in Armenia and Georgia. PARTICIPANTS: The sample comprised 1468 adults (31.6% past-month smokers). METHODS: We conducted multivariable regressions, controlling for country and sociodemographics. RESULTS: Participants were knowledgeable that the policy applied to ATPs (79.2%) and supportive of them applying to ATPs and various settings (means = 3.43 and 3.00; 1-4 = strongly support). Greater exposure to anti-tobacco media/community-based action correlated with more likely knowing that the policies applied to ATPs and greater support of the policies applying to various settings; HTP advertisement exposure correlated with less support of the policies applying to various settings. Less exposure to news opposing smoke-free policies and greater exposure to media supporting such policies correlated with greater support of the policies applying to ATPs. CONCLUSIONS: Media and community-based action may promote smoke-free policy knowledge and support. HTP advertisements may uniquely undermine smoke-free policies.

Toward a more comprehensive understanding of organizational influences on implementation: the organization theory for implementation science framework.

Introduction: Implementation is influenced by factors beyond individual clinical settings. Nevertheless, implementation research often focuses on factors related to individual providers and practices, potentially due to limitations of available frameworks. Extant frameworks do not adequately capture the myriad organizational influences on implementation. Organization theories capture diverse organizational influences but remain underused in implementation science. To advance their use among implementation scientists, we distilled 70 constructs from nine organization theories identified in our previous work into theoretical domains in the Organization Theory for Implementation Science (OTIS) framework. Methods: The process of distilling organization theory constructs into domains involved concept mapping and iterative consensus-building. First, we recruited organization and implementation scientists to participate in an online concept mapping exercise in which they sorted organization theory constructs into domains representing similar theoretical concepts. Multidimensional scaling and hierarchical cluster analyses were used to produce visual representations (clusters) of the relationships among constructs in concept maps. Second, to interpret concept maps, we engaged members of the Cancer Prevention and Control Research Network (CPCRN) OTIS workgroup in consensus-building discussions. Results: Twenty-four experts participated in concept mapping. Based on resulting construct groupings' coherence, OTIS workgroup members selected the 10-cluster solution (from options of 7-13 clusters) and then reorganized clusters in consensus-building discussions to increase coherence. This process yielded six final OTIS domains: organizational characteristics (e.g., size; age); governance and operations (e.g., organizational and social subsystems); tasks and processes (e.g., technology cycles; excess capacity); knowledge and learning (e.g., tacit knowledge; sense making); characteristics of a population of organizations (e.g., isomorphism; selection pressure); and interorganizational relationships (e.g., dominance; interdependence). Discussion: Organizational influences on implementation are poorly understood, in part due to the limitations of extant frameworks. To improve understanding of organizational influences on implementation, we distilled 70 constructs from nine organization theories into six domains. Applications of the OTIS framework will enhance understanding of organizational influences on implementation, promote theory-driven strategies for organizational change, improve understanding of mechanisms underlying relationships between OTIS constructs and implementation, and allow for framework refinement. Next steps include testing the OTIS framework in implementation research and adapting it for use among policymakers and practitioners.

Community coalitions for smoke-free environments in Armenia and Georgia: A mixed methods analysis of coalition formation, implementation and perceived effectiveness.

Effective models for aligning public health and civil society at the local level have the potential to impact various global health issues, including tobacco. Georgia and Armenia Teams for Healthy Environments and Research (GATHER) is a collaboration between Armenia, Georgia and U.S. researchers involving a community randomized trial testing the impact of community coalitions to promote smoke-free policy adoption and compliance in various settings. Community Coalition Action Theory (CCAT) was used to guide and describe coalition formation, implementation and effectiveness. Mixed methods were used to evaluate 14 municipality-based coalitions in Georgia and Armenia, including semi-structured interviews (n = 42) with coalition leaders and active members, coalition member surveys at two timepoints (n = 85 and n = 83), and review of action plans and progress reports. Results indicated successful creation of 14 multi-sectoral coalitions, most commonly representing education, public health, health care, and municipal administration. Half of the coalitions created at least one smoke-free policy in specific settings (e.g., factories, parks), and all 14 promoted compliance with existing policies through no-smoking signage and stickers. The majority also conducted awareness events in school, health care, and community settings, in addition to educating the public about COVID and the dangers of tobacco use. Consistent with CCAT, coalition processes (e.g., communication) were associated with member engagement and collaborative synergy which, in turn, correlated with perceived community impact, skills gained by coalition members, and interest in sustainability. Findings suggest that community coalitions can be formed in varied sociopolitical contexts and facilitate locally-driven, multi-sectoral collaborations to promote health. Despite major contextual challenges (e.g., national legislation, global pandemic, war), coalitions were resilient, nimble and remained active. Additionally, CCAT propositions appear to be generalizable, suggesting that coalition-building guidance may be relevant for local public health in at least some global contexts.

Smoke-free home restrictions in Armenia and Georgia: motives, barriers and secondhand smoke reduction behaviors.

BACKGROUND: Promoting smoke-free homes (SFHs) in Armenia and Georgia is timely given high smoking and secondhand smoke exposure (SHSe) rates and recent national smoke-free policy implementation. This study examined theoretical predictors (e.g. motives, barriers) of SFH status, and among those without SFHs, past 3-month SFH attempts and intent to establish SFHs in the next 3 months. METHODS: Multilevel logistic regression analyzed these outcomes using 2022 survey data from 1467 adults (31.6% past-month smokers) in Armenia (n = 762) and Georgia (n = 705). Correlates of interest included SHSe reduction behaviors and SFH motives and barriers; models controlled for country, community, age, sex, smoking status and other smokers in the home. RESULTS: In this sample, 53.6% had SFHs (Armenia: 39.2%; Georgia: 69.2%). Among those without SFHs, one-fourth had partial restrictions, no smokers in the home and/or recent SFH attempts; 35.5% intended to establish SFHs; and ∼70% of multiunit housing residents supported smoke-free buildings. We documented common SHSe reduction behaviors (opening windows, limiting smoking areas), SFH motives (prevent smell, protect children/nonsmokers) and barriers (smokers' resistance). Correlates of SFHs were being from Georgia, other smokers in the home, fewer SHSe reduction behaviors, greater motives and fewer barriers. Among participants without SFHs, correlates of recent SFH attempts were other smokers in the home, greater SHSe reduction behaviors and SFH motives, and fewer barriers; correlates of SFH intentions were being female, greater SHSe reduction behaviors, greater motives, and fewer barriers. CONCLUSIONS: SFH interventions should address motives, barriers and misperceptions regarding SHSe reduction behaviors. Moreover, smoke-free multiunit housing could have a great population impact.

Differences in Health Care Access and Use by Gender, Race, Income, Age and Employment among Residents of the Rural South.

Understanding how disparities are experienced by subpopulations within rural areas may inform efforts to mitigate persistent inequities in access to health care. Among 2,545 randomly sampled adults who completed a mailed survey in ten rural counties in Georgia as part of a health equity initiative, 50.8% of respondents were aged 35-64, 65.9% were women, 16.6% identified as Black, 36.0% worked full-time, and 39% had a high school degree or less. Significant disparities were observed in health care access, use and financial burden by age, employment status, race, and annual household income. In an examination of intersectionality of race and income, all sub-groups except for higher income Black respondents were more likely to report no health insurance and not seeing a doctor in the past 12 months due to cost relative to higher income White respondents. The findings shed insight into inequities in health care access within rural communities.

Systematic braiding of Smoke-Free Home SafeCare to address child maltreatment risk and secondhand smoke exposure: findings from a pilot study.

BACKGROUND: Exposure to secondhand tobacco smoke (SHS) and child maltreatment are preventable threats to child health. Few evidence-based interventions target both SHS and child maltreatment risk. The purpose of this paper is to describe the systematic braiding process of two evidence-based programs to address child SHS in the home and maltreatment perpetration risk, and present results from the formative work and pilot study. METHODS: The first 4 steps of the systematic braiding process were completed, including the following: (1) the identification of core elements of both programs, (2) the development of an initial draft of the braided curriculum (Smoke-Free Home SafeCare - SFH-SC), (3) an acceptability and feasibility pilot of SFH-SC with caregivers of young children who reported a smoker living in the home (N = 8), and (4) feedback collection on the braided curriculum from SafeCare Providers (N = 9). RESULTS: Experts identified common pedagogical and theoretical underpinnings for the two programs and braided Smoke-Free Homes: Some Things Are Better Outside into two SafeCare modules. Caregiver feedback from the pilot demonstrated that participants were engaged with SFH-SC and felt supported and comfortable discussing SHS intervention content with the SFH-SC Provider. Caregiver self-reports indicated a slight increase in smoke-free home rules from baseline to follow-up and a notable reduction in parent stress on the Parent Stress Index of 5.9 points (SD = 10.2). SafeCare Provider feedback following intensive review of the curriculum indicated high feasibility for SFH-SC delivery. CONCLUSIONS: Parent and Provider findings suggest SFH-SC is a viable intervention that has potential to reduce the public health impact of SHS and child maltreatment for at-risk families. PROTOCOL: The protocol for the pilot is not published elsewhere; however, the full protocol for the hybrid trial can be found here: https://clinicaltrials.gov/ct2/show/NCT05000632 . TRIAL REGISTRATION: NCT, NCT05000632. Registered 14 July 2021, there is not a separate registration number for the pilot.

Exploring dimensions of social capital in relation to healthy eating behaviours in the US rural south.

OBJECTIVE: This study examined relationships between dimensions of social capital (SC) (social trust, network diversity, social reciprocity and civic engagement) and fruit, vegetable, and sugar-sweetened beverage (SSB) consumption among rural adults. Potential moderators (neighbourhood rurality, food security, gender and race/ethnicity) were explored to develop a more nuanced understanding of the SC-healthy eating relationship. DESIGN: Data were from a 2019 mailed population-based survey evaluating an eleven-county initiative to address health equity. Participants self-reported health behaviours, access to health-promoting resources and demographics. Logistic regression models were used to analyse relationships between predictors, outcomes and moderators. SETTING: Five rural counties, Georgia, USA. PARTICIPANTS: 1120 participants. RESULTS: Among participants who lived in the country (as opposed to in town), greater network diversity was associated with consuming ≥ 3 servings of fruit (OR = 1·08; 95 % CI 1·01, 1·17, P = 0·029), yet among participants who lived in town, greater civic engagement was associated with consuming ≥ three servings of fruit (OR = 1·36; 95 % CI 1·11, 1·65, P = 0·003). Both food-secure and food-insecure participants with greater social reciprocity had lower odds of consuming 0 SSB (OR = 0·92; 95 % CI 0·86, 0·98, P = 0·014, OR = 0·92; 95 % CI 0·86, 0·99, P = 0·037, respectively). Men with greater social trust were more likely to consume 0 SSB (OR = 1·09; 95 % CI 1·01, 1·18, P = 0·038), and Whites with greater network diversity were more likely to meet daily vegetable recommendations (OR = 1·10; 95 % CI 1·01, 1·19, P = 0·028). CONCLUSIONS: Findings provide a basis for future qualitative research on potential mechanisms through which SC and related social factors influence healthy eating in rural communities.

Evaluation Design for The Two Georgias Initiative: Assessing Progress Toward Health Equity in the Rural South.

As persistent inequities in health gained increased attention nationally due to COVID-19 and racial justice protests in 2020, it has become increasingly important to evaluate both the process and outcomes associated with coalition-based efforts to address health inequities. The Two Georgias Initiative supports coalitions in 11 rural counties to (1) achieve greater health equity, (2) improve health and health care, (3) build healthier rural communities and improve social conditions that impact the health of rural populations, and (4) build community, organizational, and individual leadership capacity for health equity. Rural communities suffer significant health disparities relative to urban areas, and also experience internal inequities by race and poverty level. The evaluation framework for The Two Georgias Initiative provides a comprehensive mixed methods approach to evaluating both processes and outcomes. Early results related to community readiness and capacity to address health inequities, measured through a coalition member survey (n = 236) conducted at the end of the planning phase, suggest coalitions were in the preparation stage, with higher levels of readiness among coalition members and organizations/groups similar to the coalition members' own, lower levels among public officials and other leaders, and the lowest levels among county residents. In addition, coalition members reported more experience with downstream drivers (e.g., access to care) of health than upstream drivers (e.g., affordable housing, environmental or racial justice). By providing a logic model, evaluation questions and associated indicators, as well as a range of data collection methods, this evaluation approach may prove practical to others aiming to evaluate their efforts to address health equity.

Cancer-Related Barriers to Health Behaviors Among Adolescent and Young Adult Survivors of Pediatric Cancer and Their Families.

Adolescent and young adult (AYA) survivors of pediatric cancer and their caregivers frequently do not meet national guidelines for physical activity (PA), nutrition, or sleep. Respondents from N = 73 AYA-aged (mean [M] = 19.0 years, range = 11-30 years) survivor families completed a survey on cancer-related barriers to health behaviors. Almost all respondents (68/73, 93.2%) endorsed ≥1 cancer-specific barrier(s) to current health behaviors (median = 5, standard deviation = 3.42, range = 0-16) in their family. Cancer-related barriers to PA, nutrition, and sleep were positively correlated (PA-nutrition: r = 0.39, p = 0.001; PA-sleep: r = 0.41, p < 0.001; nutrition-sleep: r = 0.52, p < 0.001). Wellness interventions are needed to address the unique needs of AYA-aged survivors and support multiple health behaviors simultaneously.

Inequities in Physical Activity Environments and Leisure-Time Physical Activity in Rural Communities.

INTRODUCTION: Differential access to environments supportive of physical activity (PA) may help explain racial and socioeconomic disparities in leisure-time physical activity (LTPA) in rural communities. METHODS: We used baseline data from a mailed survey (N = 728) conducted in 2019 as part of an evaluation of The Two Georgias Initiative to examine the relationships among LTPA, sociodemographic characteristics, and perceived access to supportive PA environments (eg, areas around the home/neighborhood, indoor and outdoor exercise areas, town center connectivity) in 3 rural Georgia counties. RESULTS: More than half of respondents (53.5%) engaged in LTPA in the previous month. Perceptions of PA environments were generally neutral to somewhat negative. In multivariable models, overall PA environment was associated with LTPA (OR, 1.58; 95% CI, 1.06-2.35), as was annual household income >$50,000 relative to ≤$20,000 (OR, 2.72; 95% CI, 1.53-4.83) and race, with Black respondents less likely to engage in LTPA than White respondents (OR, 0.49; 95% CI, 0.29-0.85). Of the 5 PA environment domains examined, town center connectivity was significantly associated with LTPA (OR, 1.68, 95% CI, 1.20-2.36). Both the overall PA score (ß = -0.014; 95% CI, -0.029 to -0.002) and town center connectivity (ß = -0.020; 95% CI, -0.038 to -0.005) partially mediated associations between annual household income and LTPA. Areas supportive of PA around the home/neighborhood partially mediated the association by race (ß = 0.016; 95% CI, 0.001-0.034). CONCLUSION: Findings lend support for investing in town centers and racially diverse neighborhoods to increase walkability and PA infrastructure as potential strategies to reduce inequities in LTPA.

Defining the Exposome Using Popular Education and Concept Mapping With Communities in Atlanta, Georgia.

Introduction: The exposome concept provides a framework to better incorporate the environment into the study of health and disease and has been defined by academics to encompass all lifetime exposures including toxicants, diet, and lifestyle choices. However, initial applications of the exposome concept have been less apt at measuring social determinants of health, focusing primarily on conventional environmental exposures and lifestyle choices that do not reflect the complex lived experience of many communities. To bring community voice into the exposome concept, the HERCULES Exposome Research Center and its Stakeholder Advisory Board co-developed the Exposome Roadshow. We present and discuss the resulting community-exposome definition to inform and improve exposome research. Materials and Methods: Four communities from distinct areas across metro-Atlanta participated in separate 2-day Exposome Roadshow workshops with concept mapping. Aligned with a popular education approach in which community knowledge is used to work collectively for change, concept mapping provided a systematic method to collect and visualize community members' knowledge and create a shared understanding to take action. Community members brainstormed, sorted, and rated their responses to the prompt: "What in your environment is affecting your and your community's health?" Responses were analyzed and visually depicted by concept maps consisting of separate but interrelated clusters of ideas. Community members discussed and validated the maps, selecting a final map illustrating their community's exposome. Results: A total of 118 community members completed concept mapping. On average communities identified 7 clusters to define their exposome. The resulting concept maps offer a community definition of the exposome. Five major themes arose across all four communities: conventional environmental concerns, built environment, social relationships, crime and safety, and individual health and behaviors. Discussion: The resulting community-exposome definition demonstrates the importance of expanding the scope of exposures beyond traditional environmental influences to include the lived experience of individuals and communities. While newer exposome definitions align more closely with this community definition, traditional exposome methods do not routinely include these factors. To truly capture the totality of lifetime exposures and improve human health, researchers should incorporate community perspectives into exposome research.

Barriers to Creating Healthier Home Food Environments: Process Evaluation Results From 2 Home Food Environment Intervention Studies.

Few studies have identified barriers to creating a home environment more supportive of healthy eating. We examined barriers faced by participants in a randomized controlled trial and an adaptation study of the Healthy Homes/Healthy Families intervention, which uses health coaches to support low-income families in creating healthier home food environments. Coaches maintained logs of participant interactions as part of a process evaluation. We thematically analyzed logs from interactions with participants, mostly lower-income African American women (n = 114), to identify barriers for each of 8 healthy actions that serve as core elements of the intervention. Difficulty of changing current habits was a barrier for 5 of the healthy actions. No time/convenience and limited family support each influenced 2 of the healthy actions, with interpersonal barriers also stemming from social situations and visitors, including grandchildren. Cost and economic challenges were barriers for 3 of the actions. Hunger, cravings, and limited access to resources (eg, transportation, fresh fruits and vegetables) were each noted as barriers for 1 healthy action. Overall, these findings provide insight for how to better support families who are trying to improve their home food environments and highlight the need for multilevel interventions.

Low housing quality, unmet social needs, stress and depression among low-income smokers.

Smokers are at greater risk of multiple health conditions that are exacerbated by environmental hazards associated with low housing quality. However, little is known about the prevalence of low housing quality among low-income smokers. Using correlations and logistic regression, we examined associations among eight housing quality indicators - pests, water leaks, mold, lead paint, and working smoke detectors, appliances, heating, and air conditioning - and between housing quality and social needs, depressive symptoms, perceived stress, sleep problems, and self-rated health in a community-based sample of 786 low-income smokers from 6 states. Most participants were female (68%), and White (45%) or African-American (43%). One in four (27%) completed less than high school education, and 41% reported annual pre-tax household income of less than $10,000. Housing quality problems were common. Most participants (64%) reported at least one problem in their home, and 41% reported two or more problems, most commonly pest infestations (40%), water leaks (22%), lack of air conditioning (22%) and mold (18%). Lack of heat and air conditioning were correlated, as were water leaks and mold. Using logistic regression analyses controlling for participant demographic characteristics, we found that reporting more housing quality problems was associated with greater odds of worse mental and physical health outcomes. Multiple health threats, including housing quality, depressive symptoms, stress, poor sleep, and financial strain may be mutually reinforcing and compound the health consequence of smoking. Future research should seek to replicate these findings in other samples, and examine associations longitudinally to better understand causality.

Tobacco-related risk perceptions, social influences and public smoke-free policies in relation to smoke-free home restrictions: findings from a baseline cross-sectional survey of Armenian and Georgian adults in a community randomised trial.

OBJECTIVES: Given high prevalence of smoking and secondhand smoke exposure in Armenia and Georgia and quicker implementation of tobacco legislation in Georgia versus Armenia, we examined correlates of having no/partial versus complete smoke-free home (SFH) restrictions across countries, particularly smoking characteristics, risk perceptions, social influences and public smoking restrictions. DESIGN: Cross-sectional survey study design. SETTING: 28 communities in Armenia and Georgia surveyed in 2018. PARTICIPANTS: 1456 adults ages 18-64 in Armenia (n=705) and Georgia (n=751). MEASUREMENTS: We used binary logistic regression to examine aforementioned correlates of no/partial versus complete SFH among non-smokers and smokers in Armenia and Georgia, respectively. RESULTS: Participants were an average age of 43.35, 60.5% women and 27.3% smokers. In Armenia, among non-smokers, having no/partial SFHs correlated with being men (OR=2.63, p=0.001) and having more friend smokers (OR=1.23, p=0.002); among smokers, having no/partial SFHs correlated with being unmarried (OR=10.00, p=0.001), lower quitting importance (OR=0.82, p=0.010) and less favourable smoking attitudes among friends/family/public (OR=0.48, p=0.034). In Georgia, among non-smokers, having no/partial SFHs correlated with older age (OR=1.04, p=0.002), being men (OR=5.56, p<0.001), lower SHS risk perception (OR=0.43, p<0.001), more friend smokers (OR=1.49, p=0.002) and fewer workplace (indoor) restrictions (OR=0.51, p=0.026); among smokers, having no/partial SFHs correlated with being men (OR=50.00, p<0.001), without children (OR=5.88, p<0.001), daily smoking (OR=4.30, p=0.050), lower quitting confidence (OR=0.81, p=0.004), more friend smokers (OR=1.62, p=0.038) and fewer community restrictions (OR=0.68, p=0.026). CONCLUSIONS: Private settings continue to lack smoking restrictions in Armenia and Georgia. Findings highlight the importance of social influences and comprehensive tobacco legislation, particularly smoke-free policies, in changing household smoking restrictions and behaviours. TRIAL REGISTRATION NUMBER: NCT03447912.

Practice change in community health centers: A qualitative study of leadership attributes.

Introduction: This paper explores leadership attributes important for practice change in community health centers (CHCs) and assesses attributes' fit with the Full-Range Leadership Theory (FRLT). Methods: We conducted four focus groups and 15 in-depth interviews with 48 CHC leaders from several U.S. states using a modified appreciative inquiry approach. Thematic analysis was used to review transcripts for leadership concepts and code with a priori FRLT-derived and inductive codes. Results: CHC leaders most often noted attributes associated with transformational leadership as essential for practice change. Important attributes included emphasizing a collective sense of mission and a compelling, achievable vision; expressing enthusiasm about what needs to be done; and appealing to employees' analytical reasoning and challenging others to think creatively to problem solve. Few expressions of leadership fit with the transactional typology, though some did mention active vigilance to ensure standards are met, clarifying role and task requirements, and rewarding followers. Passive-avoidant attributes were rarely mentioned. Conclusions: Our results enhance understanding of leadership attributes supportive of successful practice change in CHCs.

Use of the consolidated framework for implementation research in a mixed methods evaluation of the EQUIPPED medication safety program in four academic health system emergency departments.

Background: Enhancing Quality of Prescribing Practices for Older Adults Discharged from the Emergency Department (EQUIPPED) is an effective quality improvement program initially designed in the Veterans Administration (VA) health care system to reduce potentially inappropriate medication prescribing for adults aged 65 years and older. This study examined factors that influence implementation of EQUIPPED in EDs from four distinct, non-VA academic health systems using a convergent mixed methods design that operationalized the Consolidated Framework for Implementation Research (CFIR). Fidelity of delivery served as the primary implementation outcome. Materials and methods: Four EDs implemented EQUIPPED sequentially from 2017 to 2021. Using program records, we scored each ED on a 12-point fidelity index calculated by adding the scores (1-3) for each of four components of the EQUIPPED program: provider receipt of didactic education, one-on-one academic detailing, monthly provider feedback reports, and use of order sets. We comparatively analyzed qualitative data from focus groups with each of the four implementation teams (n = 22) and data from CFIR-based surveys of ED providers (108/234, response rate of 46.2%) to identify CFIR constructs that distinguished EDs with higher vs. lower levels of implementation. Results: Overall, three sites demonstrated higher levels of implementation (scoring 8-9 of 12) and one ED exhibited a lower level (scoring 5 of 12). Two constructs distinguished between levels of implementation as measured through both quantitative and qualitative approaches: patient needs and resources, and organizational culture. Implementation climate distinguished level of implementation in the qualitative analysis only. Networks and communication, and leadership engagement distinguished level of implementation in the quantitative analysis only. Discussion: Using CFIR, we demonstrate how a range of factors influence a critical implementation outcome and build an evidence-based approach on how to prime an organizational setting, such as an academic health system ED, for successful implementation. Conclusion: This study provides insights into implementation of evidence-informed programs targeting medication safety in ED settings and serves as a potential model for how to integrate theory-based qualitative and quantitative methods in implementation studies.

Food Acquisition Practices, Body Mass Index, and Dietary Outcomes by Level of Rurality.

PURPOSE: Rural residents are more likely to be obese than urban residents. Research on how people navigate their local food environments through food acquisition behaviors, such as food shopping and restaurant use, in different types of communities may help to create a deeper understanding of the multilevel determinants of obesity. METHODS: Data are from a national sample of US adults ages 18-75. Respondents were recruited from an online survey panel in 2015 and asked about food shopping, restaurant use, diet and weight (N = 3,883). Comparisons were made by level of rurality as assessed by Rural-Urban Continuum Codes (RUCC) and self-reported rurality of the area around their home. FINDINGS: Food acquisition behaviors varied minimally by RUCC-defined level of rurality, with the exceptions of type and distance to primary food store. Rural residents drove further and were more likely to shop at small grocery stores and supercenters than were residents of semiurban or urban counties. In contrast, all of the food acquisition behaviors varied by self-reported rurality of residential areas. Respondents living in rural areas shopped for groceries less frequently, drove further, more commonly shopped at small grocery stores and supercenters, and used restaurants less frequently. In multivariable analyses, rural, small town, and suburban areas were each significantly associated with BMI and fruit and vegetable intake, but not percent energy from fat. CONCLUSION: Findings show that self-reported rurality of residential area is associated with food acquisition behaviors and may partly explain rural-urban differences in obesity and diet quality.