Comparing three methods to assess learning outcomes for a suicide prevention training program for pharmacy staff.

Objective: To examine whether pharmacists and pharmacy staff who complete a suicide prevention gatekeeper training program (Pharm-SAVES) react similarly to a written patient case, a live simulated patient (SP), and a prerecorded SP case. Methods: After completing the 30-min Pharm-SAVES training, participants completed a written patient case via survey and then, 1 month later, completed a prerecorded SP and live SP interaction via Zoom. For each assessment type, we documented whether the participant asked about suicide and referred the patient to the Suicide and Crisis Lifeline (988). Results: Participants (n = 12) asked about suicide in 8 (67 %) written patient cases, 9 (75 %) prerecorded SP cases, and 8 (67 %) live SP cases. Participants referred patients to 988 in 8 (67 %) written patient cases, 5 (42 %) prerecorded SP cases, and 10 (83 %) live SP cases. Conclusion: The number of participants who asked about suicide was similar regardless of assessment type; however, referrals to the Suicide & Crisis Lifeline happened less often with the prerecorded SP cases. Innovation: This is the first study to compare key learning outcomes of pharmacy suicide prevention gatekeeper training across written, live, and prerecorded SP encounters.

Maternal Health Legislation Enacted in Three Southeastern States in the United States Between 2018-2023: Policy Surveillance.

Background: Maternal mortality and morbidity rates in the Southeastern states of the US are among the highest in the nation. Arkansas, Mississippi, and Louisiana are ranked first, second and fifth, respectively, in maternal mortality. This retrospective policy surveillance systematically documents legislation enacted to address maternal health disparities and ameliorate maternal health. Methods: The Maternal and Child Health Legislative Database of the National Conference of State Legislators was searched for all legislation relating to maternal health in Arkansas, Louisiana, and Mississippi between 2018-2023. Two reviewers independently identified the laws passed by year and state and cross-checked to verify results. The legislative screening process is documented on a modified PRISMA flow diagram. Data extracted included the specific maternal health population targeted, the general health area addressed by the bill, and the directive of the bill. Results: 126 pieces of legislation were identified using the database (41 AR, 12 MS, and 73 LA). There were no duplicates identified; 2 laws were identified outside of the database (1 AR, 1 MS). All 128 legislation titles and summaries were screened and laws pertaining to issues other than maternal health were excluded (28 AR, 9 MS, and 48 LA). 43 full text bills were retrieved and reviewed in their entirety to assess eligibility for inclusion. 40 pieces of legislation were included (11 AR, 4 MS, and 25 LA) in this policy surveillance. Discussion: Louisiana enacted the most laws targeting and addressing maternal health, while Mississippi enacted the least. The legislation enacted addresses a broad range of health aspects, such as maternal mental health, incarcerated pregnant population reproductive health, and postpartum Medicaid coverage extension. Together with the task forces, committees, and study commissions created, the legislation enacted has the potential to address current inequities and improve maternal health outcomes in this vulnerable population by increasing access to and/or utilization of care, extending duration and/or type of evidence-based care available, and decreasing racial disparities in maternal health with the eventual goal of rooting out preventable morbidity and mortality.

A randomized controlled trial protocol for a virtual, scalable suicide prevention gatekeeper training program for community pharmacy staff (Pharm-SAVES).

Background: Suicide prevention gatekeeping is a skill that may support community (retail) pharmacists in managing patients who present with suicide warning signs. A brief, virtual, case-based training intervention was tailored to the retail setting (Pharm-SAVES). To test training effectiveness, a randomized controlled trial (RCT) protocol was developed for use in pharmacies across four states. Objective: To introduce the trial protocol for assessing the effectiveness for increasing the proportion of staff who recognize patients displaying warning signs and self-report engaging in gatekeeping, including asking if the patient is considering suicide. Methods: This study uses a parallel cluster-randomized controlled trial to recruit 150 pharmacy staff in community pharmacies in four states with two groups (intervention and control). The control group completes Pharm-SAVES online suicide prevention gatekeeper training and all assessment surveys at baseline after training and at 1-month follow-up. The experimental group completes all control group training and assessments plus interactive video role-play patient cases. Conclusion: We hypothesize that compared to those in the control group, experimental group trainees exposed to the interactive video role play patient cases will be more likely to recognize warning signs in patient cases and self-report engaging in gatekeeping.

Addressing COVID-19 vaccine hesitancy in rural community pharmacies: a protocol for a stepped wedge randomized clinical trial.

BACKGROUND: Uptake of COVID-19 vaccines remains problematically low in the USA, especially in rural areas. COVID-19 vaccine hesitancy is associated with lower uptake, which translates to higher susceptibility to SARS-CoV-2 variants in communities where vaccination coverage is low. Because community pharmacists are among the most accessible and trusted health professionals in rural areas, this randomized clinical trial will examine implementation strategies to support rural pharmacists in delivering an adapted evidence-based intervention to reduce COVID-19 vaccine hesitancy. METHODS: We will use an incomplete stepped wedge trial design in which we will randomize 30 rural pharmacies (unit of analysis) to determine the effectiveness and incremental cost-effectiveness of a standard implementation approach (consisting of online training that describes the vaccine hesitancy intervention, live webinar, and resource website) compared to adding on a virtual facilitation approach (provided by a trained facilitator in support of the delivery of the vaccine hesitancy counseling intervention by pharmacists). The intervention (ASORT) has been adapted from an evidence-based vaccine communication intervention for HPV vaccines through a partnership with rural pharmacies in a practice-based research network in seven southern US states. ASORT teaches pharmacists how to identify persons eligible for COVID-19 vaccination (including a booster), solicit and address vaccine concerns in a non-confrontational way, recommend the vaccine, and repeat the steps later if needed. The primary trial outcome is fidelity to the ASORT intervention, which will be determined through ratings of recordings of pharmacists delivering the intervention. The secondary outcome is the effectiveness of the intervention, determined by rates of patients who agree to be vaccinated after receiving the intervention. Other secondary outcomes include feasibility, acceptability, adoption, reach, and cost. Cost-effectiveness and budget impact analyses will be conducted to maximize the potential for future dissemination and sustainability. Mixed methods will provide triangulation, expansion, and explanation of quantitative findings. DISCUSSION: This trial contributes to a growing evidence base on vaccine hesitancy interventions and virtual-only facilitation of evidenced-based practices in community health settings. The trial will provide the first estimate of the relative value of different implementation strategies in pharmacy settings. TRIAL REGISTRATION: NCT05926544 (clinicaltrials.gov); 07/03/2023.

Telehealth Diabetes Prevention Program for Adults With Prediabetes in an Academic Medical Center Setting: Protocol for a Hybrid Type III Trial.

BACKGROUND: Diabetes is a costly epidemic in the United States associated with both health and economic consequences. These consequences can be mitigated by participation in structured lifestyle change programs such as the National Diabetes Prevention Program (DPP) led by the Centers for Disease Control and Prevention. Mississippi consistently has among the highest rates of diabetes and prediabetes nationally. Implementing the National DPP through large health care systems can increase reach and accessibility for populations at the highest risk for diabetes. Translational research on the National DPP in Mississippi has not been studied. OBJECTIVE: This study aims to evaluate the implementation and impact of the National DPP delivered using telehealth modalities at the University of Mississippi Medical Center in Jackson, Mississippi. METHODS: An effectiveness-implementation hybrid type III research design is proposed. The study design is guided by the Reach, Effectiveness, Adoption, Implementation, and Maintenance framework and the Practical, Robust Implementation and Sustainability Model. Participants are being recruited via provider referral, and the DPP is being delivered by trained lifestyle coaches. Study participants include adult (≥18 years) patients eligible for the DPP with at least 1 encounter at 1 of 3 ambulatory clinic specialties (lifestyle medicine, family medicine, and internal medicine) between January 2019 and December 2023. The National DPP eligibility criteria include a BMI ≥25 kg/m2 and hemoglobin A1c between 5.7% and 6.4%. The University of Mississippi Medical Center criteria include Medicare or Medicaid beneficiaries. The University of Mississippi Medical Center's a priori implementation plan was developed using the Consolidated Framework for Implementation Research and includes 23 discrete strategies. The primary aim will use an embedded mixed method process analysis to identify and mitigate challenges to implementation. The secondary aim will use a nonrandomized quasi-experimental design to assess the comparative effectiveness of the DPP on health care expenditures. A propensity score matching method will be implemented to compare case subjects to control subjects. The primary outcomes include patient referrals, participant enrollment, retention, engagement, the incidence of diabetes, and health care resource use and costs. RESULTS: At baseline, of the 26,151 patients across 3 ambulatory clinic specialties, 1010 (3.9%) had prediabetes and were eligible for the National DPP. Of the 1010 patients, more than half (n=562, 55.6%) were aged 65 years or older, 79.5% (n=803) were Medicare beneficiaries, 65.9% (n=666) were female, and 70.8% (n=715) were obese. CONCLUSIONS: This is the first translational study of the National DPP in Mississippi. The findings will inform implementation strategies impacting the uptake and sustainability of the National DPP delivered in an academic medical setting using distance learning and telehealth modalities. TRIAL REGISTRATION: ClinicalTrials.gov NCT04822480; https://clinicaltrials.gov/study/NCT03622580. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/50183.

COVID-19 booster vaccination in rural community pharmacies.

This study assessed rural community pharmacists' attitudes about COVID-19 vaccine booster doses and explored whether rural pharmacies offered these booster doses. Of the 80 rural Southeastern U.S. pharmacists who completed the online survey, the majority (n = 68, 85 %) offered boosters and 42 (52.5 %) had received the booster themselves. Alabama and Mississippi offered boosters less often than other states, and pharmacists who had foregone receiving COVID-19 vaccination or booster doses were less likely to offer the booster to their patients. Additionally, many pharmacists reported that they and their patients felt the booster was not needed. Community pharmacies provide access points for the COVID-19 booster in rural areas. Interventions for both pharmacists and patients are needed to address hesitancy and improve booster uptake in these communities.

School-based obesity prevention programs in rural communities: a scoping review.

OBJECTIVE: The objective of this review was to examine existing literature and conceptually map the evidence for school-based obesity prevention programs implemented in rural communities, as well as identify current gaps in the literature. INTRODUCTION: Pediatric obesity is a significant public health condition worldwide. Rural residency places children at increased risk of obesity. Schools have been identified as an avenue for obesity prevention in rural communities. INCLUSION CRITERIA: We considered citations focused on children (5 to 18 years of age) enrolled in a rural educational setting. We included obesity prevention programs delivered in rural schools that focused on nutrition or dietary changes, physical activity or exercise, decreasing screen time, or combined nutrition and physical activity that aimed to prevent childhood obesity. We included all quantitative, qualitative, and mixed methods research designs, as well as text and opinion data. METHODS: A search was conducted of published and unpublished studies in English from 1990 through April 2020 using PubMed, CINAHL Complete, ERIC, Embase, Scopus, Academic Search Premier, Cochrane Register of Controlled Trials, and ClinicalTrials.gov. Gray literature was also searched. After title and abstract review, potentially relevant citations were retrieved in full text. The full texts were assessed in detail against the inclusion criteria by 2 independent reviewers. Included citations were reviewed and data extracted by 2 independent reviewers and captured on a spreadsheet targeting the review objectives. RESULTS: Of the 105 studies selected for full-text review, 72 (68.6%) were included in the final study. Most of the studies (n = 50) were published between 2010 and 2019 and were conducted in the United States (n = 57). Most studies included children in rural elementary or middle schools (n = 57) and targeted obesity prevention (n = 67). Teachers implemented the programs in half of the studies (n = 36). Most studies included a combination of physical activity and nutrition components (n = 43). Other studies focused solely on nutrition (n = 9) or physical activity (n = 9), targeted obesity prevention policies (n = 9), or other components (n = 8). Programs ranged in length from weeks to years. Overall, weight-related, physical activity-specific, and nutrition-specific outcomes were most commonly examined in the included citations. CONCLUSIONS: Obesity prevention programs that focused on a combination of physical activity and nutrition were the most common. Multiple outcomes were examined, but most programs included weight-specific and health behavior-specific outcomes. The length and intensity of rural school-based obesity prevention programs varied. More research examining scientific rigor and specific outcomes of rural school-based obesity prevention programs is needed.

Addressing the opioid epidemic through community pharmacy engagement: Study protocol for a randomized controlled trial.

BACKGROUND: Despite the authority to dispense naloxone, pharmacists have been reluctant to offer and dispense it, often due to discomfort communicating about the sensitive topic of opioid overdose. Because existing online naloxone trainings do not sufficiently address how to communicate effectively with patients about naloxone, Nalox-Comm, a training module designed to improve pharmacists' self-efficacy to engage in naloxone discussions, was developed. OBJECTIVE: To describe the study protocol to evaluate the effectiveness of the Nalox-Comm training module on naloxone dispensing rates. METHODS: A randomized controlled trial, which began in July 2021, is used to evaluate the pre-post Nalox-Comm training intervention. Sixty pharmacists are being recruited from 62 pharmacies part of a single grocery store chain in rural counties of the southeastern United States. After completing a baseline survey, pharmacists are observed by simulated patients (SPs) who rate the quality of their pre-training naloxone communication. Pharmacists are then invited to complete either a basic online naloxone training module (control group) or a newly developed Nalox-Comm training (experimental group), after which they complete a post-training survey and are observed a second time by SPs. Three months post-training, study participants complete a final follow-up survey. Naloxone dispensing records are obtained from each participating pharmacy to assess change in naloxone dispensing rates. CONCLUSION: Informed by rural pharmacist stakeholders, the Nalox-Comm training module addresses communication barriers specific to rural communities. Compared to those in the control group, we hypothesize that pharmacies in the experimental group will dispense more naloxone in the three months post-training intervention.

Rural community pharmacists' ability and interest in administering COVID-19 vaccines in the Southern United States.

BACKGROUND: Community pharmacists are often the most accessible health professional in rural areas, which makes them well positioned to increase vaccine access in their communities. This study sought to document rural pharmacists' ability to and interest in administering coronavirus disease 2019 (COVID-19) vaccinations. METHODS: A sample of community pharmacists participating in a rural community pharmacy practice-based research network in the United States completed an online survey that assessed (1) demographic characteristics, (2) previous COVID-19 vaccine training, and (3) ability to administer COVID-19 vaccines. Data were collected between late December 2020 and mid-February 2021. Descriptive statistics and correlations were calculated. RESULTS: A total of 69 of 106 pharmacists completed the survey (response rate = 65%). Approximately half of pharmacists were ready (52%) or actively taking steps (39%) to provide COVID-19 vaccines in the next 6 months. Pharmacies had a median of 2 staff members who were authorized to administer COVID-19 vaccines. Almost half (46%) estimated they could administer more than 30 vaccinations per day. Most pharmacies could store vaccines at standard refrigeration (90%) and freezing (83%) levels needed for thawed and premixed vaccines, respectively. Most pharmacists planned to access COVID-19 vaccines through an agreement with a state or local public health entity (48%) or by ordering through group purchasing organizations (46%). Only 23% of pharmacists had received any COVID-19 vaccine training, and only 48% very much wanted to get the vaccine themselves. Several variables, including pharmacy type and pharmacists' vaccine attitudes and previous COVID-19 training, were significantly associated (P < 0.05) with the anticipated number of COVID-19 vaccines pharmacies could administer daily. CONCLUSION: Even early in the nation's COVID-19 vaccine rollout, most rural pharmacies were interested in and preparing to administer COVID-19 vaccines. Few rural pharmacists had received COVID-19 training, and many expressed some hesitancy to receive the vaccine themselves. The number of vaccines pharmacists could administer varied with pharmacy and pharmacist characteristics.

Telehealth Diabetes Prevention Intervention for the Next Generation of African American Youth: Protocol for a Pilot Trial.

BACKGROUND: In 1999, type 2 diabetes mellitus (T2DM) was identified as an emerging epidemic in youth, and racial and ethnic minority youth were identified with high risk. Two decades later, no gold standard T2DM prevention intervention has been established for this population. OBJECTIVE: This study tests the efficacy of a telehealth diabetes prevention intervention for African American (AA) families with children with risk for T2DM. Concurrently, investigators aim to evaluate an implementation strategy for the uptake of the intervention by the University of Mississippi Medical Center's (UMMC) pediatric weight management clinic. METHODS: This single-arm trial will enroll 20 parents with overweight or obesity of children (8-11 years) with overweight or obesity, both of whom are at risk for T2DM. Parents will meet in small groups (5 parents per group) weekly for 11 weeks and then monthly for 4 monthly maintenance sessions via videoconference using Wi-Fi-enabled iPads with cellular connectivity. The intervention will be adapted from the National Diabetes Prevention Program and Power to Prevent, a diabetes prevention program tailored for AA families. The same lifestyle intervention facilitated by a racially concordant lifestyle coach trained in the Diabetes Prevention Program will be delivered to all groups (n=4). Participants will be recruited in-person during patient encounters at the UMMC's pediatric weight management clinic. Sessions will consist of dietary and physical activity behavior change strategies facilitated using problem-solving and goal-setting skills. The implementation strategy has 2 targets: the pediatric weight management clinic site and clinical team and parents of children at risk for T2DM engaged in intensive obesity treatment to prevent T2DM. The multifaceted implementation protocol includes 4 discrete strategies: creating a new clinical team, changing the service site, intervening with families, and promoting organizational readiness for change. RESULTS: Recruitment and enrollment began in December 2020, and the intervention is scheduled to be delivered to the first cohort of parents in March 2021. The results are expected to be submitted for publication beginning in November 2021 through 2022. The primary outcome measure for the pilot trial will include changes from baseline to 12 and 30 weeks in the child BMI z score and parent BMI. The implementation evaluation will include multiple measures of feasibility, acceptability, appropriateness, fidelity, and efficacy. This protocol was approved by the UMMC's Institutional Review Board (#2020V0249). CONCLUSIONS: The proposed intervention approach is supported by the scientific literature and is scalable given the current and future health care subsidies for telehealth. Findings from this pilot trial will begin to address critical barriers to defining a gold standard lifestyle intervention for AA families with children at risk for T2DM. If effective, the intervention could be feasibly disseminated to treat obesity and prevent T2DM in high-risk AA pediatric populations. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25699.

Recruitment planning for clinical trials with a vulnerable perinatal adolescent population using the Clinical Trials Transformative Initiative framework and principles of partner and community engagement.

Recruitment planning is needed to establish a foundation for obesity prevention research with high risk, disadvantaged perinatal adolescent populations. In the context of developing clinical trial protocols, investigators partnered with Mississippi's Nutrition Program for Women, Infants and Children (WIC) and adopted the Clinical Trials Transformative Initiative (CTTI) framework for recruitment planning to identify and mitigate challenges to recruitment early in the clinical trial development process. The recruitment protocol consisted of 20 passive strategies grounded in principles of partner and community engagement and was flexible, accommodating, altruistic, community-focused, and minimally burdensome to partners and participants. The recruitment goal included 150 adolescent-coparticipant dyads and 145 dyads (96.7%) were successfully recruited. Investigators demonstrated the feasibility of recruiting a disadvantaged and vulnerable perinatal adolescent population that is underrepresented in health research, in one of the most persistently impoverished and poor health regions in the U.S. Four important aspects of recruitment planning using the CTTI framework are discussed including: (1) establishing partnerships with trusted community resources is a paramount investment; (2) dedicating time and resources to know and go to your community is invaluable; (3) fostering trust by offering convenient, continuous and clear communication; and (4) encouraging collaboration and participation through limiting partner and participant burden. Establishing organizational and community partnership requires a substantial amount of invaluable time and fosters recruitment success. Following the CTTI recommendations for recruitment planning led to a robust recruitment protocol that will be used in future intervention trials with an understudied perinatal adolescent population with high risk for poor maternal and fetal health outcomes.

Recruitment, Retention, and Engagement Strategies for Exercise Interventions With Rural Antenatal Adolescents: Qualitative Interviews With WIC Providers.

Public health stakeholder engagement is integral to developing effective public health interventions. The perspectives of women enrolled in the Special Supplemental Nutritional Program for Women, Infants, and Children (WIC) have often been sought when designing WIC-based interventions; however, the perspectives of WIC providers are underrepresented. The goal of this investigation was to explore the experiences of WIC providers who counsel adolescent clients and to identify strategies for recruitment, retention, and engagement of adolescents in an antenatal exercise intervention. Qualitative interviews were conducted with WIC providers (N = 9) in the Mississippi Delta, a rural, predominantly African American region in northwest Mississippi. From our data emerged 4 themes and 4 hypothesized strategies for recruitment, retention, and engagement of adolescent WIC clients and their parents in a future antenatal exercise intervention that will be implemented through WIC. Engaging the perspectives of WIC providers was a critical first step in understanding the context for this intervention.

Effects of eHealth interventions on physical activity and weight among pregnant and postpartum women and the sociodemographic characteristics of study populations: a systematic review protocol.

OBJECTIVE: The objective of this review is to evaluate the impact of electronic health (eHealth) interventions on physical activity and weight changes among pregnant and/or postpartum populations and to describe the sociodemographic characteristics of the study populations. INTRODUCTION: The American College of Obstetricians and Gynecologists recommends 20 minutes of daily physical activity during pregnancy and postpartum. Few pregnant women are physically active and among those who are, physical activity levels decline as pregnancy progresses and during postpartum. Behavioral eHealth interventions offer convenient and frequent accessibility at low cost and high reach. A search of the extant literature including PROSPERO, MEDLINE (PubMed), the Cochrane Database of Systematic Reviews and the JBI Database of Systematic Reviews and Implementation Reports revealed no published or in-progress reviews examining eHealth physical activity interventions among pregnant and/or postpartum populations. INCLUSION CRITERIA: Studies of eHealth interventions including pregnant and/or within one-year postpartum populations will be included. METHODS: This review will be conducted in accordance with JBI methodology for systematic reviews of effectiveness. The search strategy will aim to locate studies from the inception of each database. Citations will be collated, and duplicates removed. Titles and abstracts will be screened for eligibility against the inclusion criteria and relevant studies retrieved. Included studies will be appraised for methodological quality using JBI standardized critical appraisal instruments. Extracted data will include study methods, intervention design and outcomes (physical activity, weight, participant sociodemographic characteristics). The Grading of Recommendations, Assessment, Development and Evaluation approach for grading the certainty of evidence will be followed. SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42020124611.

School-based obesity prevention programs in rural communities: a scoping review protocol.

OBJECTIVE: The objective of this scoping review is to map the available literature on school-based obesity prevention programs in rural communities. INTRODUCTION: Significant health disparities are associated with childhood obesity, and these disparities disproportionately affect children in disadvantaged communities, such as rural areas. Youth in rural areas are 26% more likely to be obese than youth in urban communities. To combat obesity in children, schools have become an avenue for educating children about the importance of healthy diet and physical activity. Although many school-based obesity prevention programs have been implemented in recent years, more information is needed on programs in rural communities. INCLUSION CRITERIA: This scoping review will consider studies that include children 5 to 18 years of age who are enrolled in elementary, middle or high school in a rural setting and that investigate school-based obesity prevention programs. Studies that include children who are in non-rural areas, who are home-schooled, who are in an alternative setting (e.g. juvenile detention) or who are hospitalized will be excluded. Studies published in English since 1990 will be included. METHODS: Multiple databases will be searched, including PubMed, CINAHL, ERIC, Embase, Scopus and Academic Search Premier. Trials registers and gray literature will also be searched. After screening the titles and abstracts of identified citations, potentially relevant studies will be retrieved in full. Data will be extracted by independent reviewers and presented in a diagrammatic or tabular form, accompanied by a narrative summary.

Men's Preferences for Physical Activity Interventions: An Exploratory Study Using a Factorial Survey Design Created With R Software.

Effective exercise interventions are needed to improve quality of life and decrease the impact of chronic disease. Researchers suggest males have been underrepresented in exercise intervention studies, resulting in less understanding of their exercise practices. Findings from preference survey methods suggest reasonable association between preference and behavior. The purpose of the research described in this article was to use factorial survey, a preference method, to identify the characteristics of exercise interventions most likely to appeal to male participants, so preferences might be incorporated into future intervention research. The research was guided by the framework of Bandura's social cognitive theory, such that variations in individual, environmental, and behavioral factors were incorporated into vignettes. Participants included 53 adult male nonadministrative staff and contract employees at a public university in the Southeastern United States, who each scored 8 vignettes resulting in 423 observations. Multilevel models were used to assess the influence of the factors. Participants scored vignettes that included exercising with a single partner, playing basketball, and exercising in the evening higher than vignettes with other options. Qualitative analysis of an open response item identified additional alternatives in group size, participant desire for coaching support, and interest in programs that incorporate a range of activity alternatives. Findings from this research were consistent with elements of social cognitive theory as applied to health promotion. Factorial surveys potentially provide a resource effective means of identifying participants' preferences for use when planning interventions. The addition of a single qualitative item helped clarify and expand findings from statistical analysis.

A Systematic Review of Rural, Theory-based Physical Activity Interventions.

OBJECTIVES: This systematic review synthesized the scientific literature on theory-based physical activity (PA) interventions in rural populations. METHODS: PubMed, PsycINFO, and Web of Science databases were searched to identify studies with a rural study sample, PA as a primary outcome, use of a behavioral theory or model, randomized or quasi-experimental research design, and application at the primary and/or secondary level of prevention. RESULTS: Thirty-one studies met our inclusion criteria. The Social Cognitive Theory (N = 14) and Transtheoretical Model (N = 10) were the most frequently identified theories; however, most intervention studies were informed by theory but lacked higher-level theoretical application and testing. Interventions largely took place in schools (N = 10) and with female-only samples (N = 8). Findings demonstrated that theory-based PA interventions are mostly successful at increasing PA in rural populations but require improvement. CONCLUSIONS: Future studies should incorporate higher levels of theoretical application, and should explore adapting or developing rural-specific theories. Study designs should employ more rigorous research methods to decrease bias and increase validity of findings. Follow-up assessments to determine behavioral maintenance and/or intervention sustainability are warranted. Finally, funding agencies and journals are encouraged to adopt rural-urban commuting area codes as the standard for defining rural.

Not Enough Time in the Day: A Qualitative Assessment of In-School Physical Activity Policy as Viewed by Administrators, Teachers, and Students.

BACKGROUND: In recent decades, the alignment of health and education has been at the forefront of school reform. Whereas the establishment of national in-school physical activity (ISPA) recommendations and state-level mandates demonstrates success, there has been less achievement in areas that address health disparities. The purpose of this investigation was to explore barriers and facilitators to implementing state-mandated ISPA policies in the Mississippi Delta. METHODS: Focus groups or interviews were conducted with district administrators, school principals, teachers, and students. A total of 2 semistructured moderator guides were developed to focus on (1) student ISPA practices and preferences and (2) facilitators and barriers to implementing ISPA policies and practices. RESULTS: A total of 6 themes were developed. In that, 2 themes addressed participant-described barriers (primary challenges and interferences and excuses). Three themes highlighted participant-described facilitators (compromises, things that work, and being active at school). Finally, 1 theme encompassed the participant-described need to address educating the whole child. CONCLUSIONS: There is a critical need for meaningful and relevant solutions to circumvent challenges to implementing ISPA policies and practices in the Mississippi Delta. The Whole School, Whole Community, Whole Child model offers a broad means of visualizing rural, low-income, racially concentrated schools to circumvent challenges and foster ISPA policies and practices.

Academic Health Center-Rural Community Collaborations: 'Healthy Linkages' to Improve the Health of Rural Populations.

PURPOSE: The purpose of this paper is to describe an extant theoretical model framing Mississippi Healthy Linkages, a successful academic-community partnership undergirding an emergency department (ED) diversion program. DESCRIPTION: The partnership between the University of Mississippi Medical Center, Mississippi State Department of Health, and Federally Qualified Health Centers is grounded in the Structuration Model of Collaboration and utilizes collective action to support an organized system of care linking academic and community care settings to address health disparities, particularly for rural and vulnerable populations. ASSESSMENT: Partners identified three interconnected segments of an integrated patient referral system to improve patient-level care, including galvanization of primary care services for ED patients, connection of primary care patients to specialty care, and linking ED patients with aftercare services. CONCLUSIONS: This academic-community partnership has significant benefits for linking health care and public health systems to address remote and vulnerable population health issues and serves as a model to be replicated in other areas of the United States, particularly in the Southeast and in rural areas.

Rural Active Living: A Call to Action.

Rural residents are less physically active than their urban counterparts and disproportionately affected by chronic diseases and conditions associated with insufficient activity. While the ecological model has been successful in promoting and translating active living research in urban settings, relatively little research has been conducted in rural settings. The resulting research gap prohibits a comprehensive understanding and application of solutions for active living in rural America. Therefore, the purpose of this article was to assess the evidence base for an ecological model of active living for rural populations and outline key scientific gaps that inhibit the development and application of solutions. Specifically, we reexamined the 4 domains conceptualized by the model and suggest that there is a dearth of research specific to rural communities across all areas of the framework. Considering the limited rural-specific efforts, we propose areas that need addressing to mobilize rural active living researchers and practitioners into action.