Adapting a cooking, food budgeting and nutrition intervention for a rural community of American Indians with type 2 diabetes in the North-Central United States.

American Indian (AI) communities experience persistent diabetes-related disparities, yet few nutrition interventions are designed for AI with type 2 diabetes or address socio-contextual barriers to healthy eating. We describe our process of adapting the evidence-based Cooking Matters® program for use by AI adults with type 2 diabetes in a rural and resource-limited setting in the North-Central United States. We conducted three focus groups with AI adults with diabetes to (i) identify Cooking Matters® adaptations and (ii) gather feedback on appropriateness of the adapted intervention using Barrera and Castro's cultural adaptation framework. Transcripts were coded using an inductive, constant comparison approach. Queries of codes were reviewed to identify themes. Contextual considerations included limited access to grocery stores and transportation barriers, reliance on government food assistance and the intergenerational burden of diabetes. Adaptations to content and delivery included incorporating traditional and locally available foods; appealing to children or others in multigenerational households and prioritizing visual over written content. Our use of Barrera and Castro's framework adds rigor and structure to the cultural adaptation process and increases the likelihood of future intervention success. Other researchers may benefit from using this framework to guide the adaptation of evidence-based interventions in AI communities.

Diet quality in adults with cerebral palsy: a modifiable risk factor for cardiovascular disease prevention.

AIM: To assess diet quality and its relationship with cardiovascular health measures for adults with cerebral palsy (CP). METHOD: A convenience sample of 45 adults with CP (26 females, 19 males; mean age 35y 10mo [SD 14y 9mo]). were recruited for this cross-sectional study. Demographic, medical, and Gross Motor Function Classification System (GMFCS) information were obtained through in-person visits. Participants completed two 24-hour dietary recalls using the Automated Self-Administered 24-hour Dietary Assessment Tool. Specific macronutrient intake was compared to 2015 to 2020 US Department of Agriculture (USDA) guidelines. Other data included body mass index (BMI), waist-to-hip ratio (WHR), blood pressure, and hemoglobin A1c (HgA1c;n=43). RESULTS: Adults across GMFCS levels I to V were enrolled, 20 participants were in GMFCS levels IV or V. Mean calorie intake was 1777.91/day (SD 610.54), while sodium intake was 3261.75mg/day (SD 1484.92). Five participants met USDA vegetable and seven fruit guidelines. None met whole grain targets. Sixteen were overweight/obese by BMI. Sixteen participants without hypertension diagnoses had elevated blood pressure and nine had abnormal HgA1c without prediabetes/diabetes history. Percent calories from saturated fat was inversely associated with WHR in unadjusted and adjusted models (p=0.002 and p=0.003 respectively); all other dietary recommendations assessed (total calories, sodium, and sugar) were non-significant. Post hoc analyses were unchanged using 2020 to 2025 USDA guidelines. INTERPRETATION: Assessment of nutrient intake and diet quality is feasible and warrants further study in adults with CP, as USDA guidelines are largely unmet. What this paper adds Adults with cerebral palsy (CP) do not meet US Department of Agriculture dietary quality recommendations. Prediabetes and hypertension may be common, but unrecognized, in adults with CP. Screening for nutrient intake and diet quality should be performed to facilitate nutritional counseling.

Cooking for Health: a healthy food budgeting, purchasing, and cooking skills randomized controlled trial to improve diet among American Indians with type 2 diabetes.

BACKGROUND: The prevalence of poor diet quality and type 2 diabetes are exceedingly high in many rural American Indian (AI) communities. Because of limited resources and infrastructure in some communities, implementation of interventions to promote a healthy diet is challenging-which may exacerbate health disparities by region (urban/rural) and ethnicity (AIs/other populations). It is critical to adapt existing evidence-based healthy food budgeting, purchasing, and cooking programs to be relevant to underserved populations with a high burden of diabetes and related complications. The Cooking for Health Study will work in partnership with an AI community in South Dakota to develop a culturally-adapted 12-month distance-learning-based healthy food budgeting, purchasing, and cooking intervention to improve diet among AI adults with type 2 diabetes. METHODS: The study will enroll 165 AIs with physician-diagnosed type 2 diabetes who reside on the reservation. Participants will be randomized to an intervention or control arm. The intervention arm will receive a 12-month distance-learning curriculum adapted from Cooking Matters® that focuses on healthy food budgeting, purchasing, and cooking skills. In-person assessments at baseline, month 6 and month 12 will include completion of the Nutrition Assessment Shared Resources Food Frequency Questionnaire and a survey to assess frequency of healthy and unhealthy food purchases. Primary outcomes of interest are: (1) change in self-reported intake of sugar-sweetened beverages (SSBs); and (2) change in the frequency of healthy and unhealthy food purchases. Secondary outcomes include: (1) change in self-reported food budgeting skills; (2) change in self-reported cooking skills; and (3) a mixed-methods process evaluation to assess intervention reach, fidelity, satisfaction, and dose delivered/received. DISCUSSION: Targeted and sustainable interventions are needed to promote optimal health in rural AI communities. If effective, this intervention will reduce intake of SSBs and the purchase of unhealthy foods; increase the purchase of healthy foods; and improve healthy food budgeting and cooking skills among AIs with type 2 diabetes - a population at high risk of poor health outcomes. This work will help inform future health promotion efforts in resource-limited settings. TRIAL REGISTRATION: This study was registered on ClinicalTrials.gov on October 9, 2018 with Identifier NCT03699709 .

Local Health Departments' Capacity for Workplace Health Promotion Programs to Prevent Chronic Disease: Comparison of Rural, Micropolitan, and Urban Contexts.

OBJECTIVE: To examine local health department (LHD) contexts, capacity for, and interest in partnering with employers on workplace health promotion programs (WHPPs) for chronic disease prevention. DESIGN: Qualitative interviews with LHD directors. SETTING: LHDs from 21 counties in 10 states. PARTICIPANTS: Twenty-one LHD directors. MAIN OUTCOME MEASURESS: Experiences and perceptions of existing partnerships, decision making, funding, data needs, and organizational capacity for WHPP partnerships with employers. RESULTS: We identified 3 themes: (1) LHDs see the value of partnering with employers but lack the capacity to do so effectively; (2) while LHDs base priorities on community need, funding ultimately drives decision making; and (3) rural, micropolitan, and urban LHDs differ in their readiness and capacity to work with employers. CONCLUSIONS: Understanding LHDs' partnership capacity and context is essential to the successful implementation of WHPP partnerships with employers. Expanding these partnerships may require additional financial investments, particularly among rural LHDs.

Characterizing the local food environment and grocery-store decision making among a large American Indian community in the north-central USA: qualitative results from the Healthy Foods Healthy Families Feasibility Study.

OBJECTIVE: Perceptions of social-contextual food environments and associated factors that influence food purchases are understudied in American Indian (AI) communities. The purpose of the present study was to: (i) understand the perceived local food environment; (ii) investigate social-contextual factors that influence family food-purchasing choices; and (iii) identify diet intervention strategies. DESIGN: This qualitative study consisted of focus groups with primary household shoppers and key-informant interviews with food retailers, local government food assistance programme directors and a dietitian. An inductive, constant comparison approach was used to identify major themes. SETTING: A large AI reservation community in the north-central USA. PARTICIPANTS: Four focus groups (n 31) and seven key-informant interviews were conducted in February and May 2016. RESULTS: Perceptions of both the higher cost of healthy foods and limited access to these foods influenced the types of foods participants purchased. Dependence on government assistance programmes and the timing of benefits also contributed to the types of foods purchased. Participants described purchasing foods based on the dietary needs and preferences of their children. Suggestions for improving the purchase and consumption of healthy foods included: culturally relevant and family-centred cooking classes and workshops focused on monthly food budgeting. Participants also emphasized the importance of involving the entire community in healthy eating initiatives. CONCLUSIONS: Cost and access were the major perceived barriers to healthy eating in this large rural AI community. Recommended interventions included: (i) family-friendly and culturally relevant cooking classes; (ii) healthy food-budgeting skills training; and (iii) approaches that engage the entire community.

Smoking and experiences with tobacco cessation among men who have sex with men: New Orleans, 2011.

Smoking continues to be a problem in the United States, particularly among men who have sex with men (MSM). The current study assesses the prevalence of current and lifetime smoking as well as cessation experiences in a sample of MSM. Two-thirds of the sample had ever smoked tobacco and 50 % of MSM were current smokers. Prevalence of current smoking in this sample was higher than comparative data obtained from HIV positive patients at a local clinical population. Smoking was found to be associated with HIV status, race, age, education, income and alcohol use. A high proportion of MSMs social networks were smokers especially among current smokers. Continued efforts targeting or linking MSM into tobacco cessation efforts are recommended.

Association of Housing Instability with Obesity Status Among Insured Adults.

INTRODUCTION: Obesity affects four in ten US adults. One of the most prevalent health-related social risk factors in the US is housing instability, which is also associated with cardiovascular health outcomes, including obesity. The objective of this research brief is to examine the association between housing instability with obesity status among a representative sample of insured adults across seven integrated health systems. METHODS: Kaiser Permanente National Social Needs Survey used a multistage stratified sampling framework to administer a cross-sectional survey across seven integrated health systems (administered Jan.-Sept. 2020). Survey data were linked with electronic health records (EHR). Housing instability was categorized into levels of risk: (1) "No Risk"; (2) "Moderate Risk"; and (3) "Severe Risk." Based on established BMI thresholds, obesity, and severe obesity served as the primary outcome variables. In 2023, weighted multivariable logistic regression accounted for the complex sampling design and response probability and controlled for covariates. RESULTS: The analytic cohort comprised 6,397 adults. Unadjusted weighted prevalence of obesity and severe obesity was 31.1% and 5.3%, respectively; and 15.5% reported housing instability. Adjusted regression models showed that the odds of severe obesity was nearly double among adults exposed to severe housing instability (Adjusted OR=1.93; 95% CI 1.14-3.26). Other BMI categories were not associated with housing instability. CONCLUSIONS: Among a representative cohort of insured adults, this study suggested increasing levels of housing instability are associated with increasing levels of obesity. Future research should further explore the temporal, longitudinal, and independent association of housing instability with obesity.

Codesigning Online Continuing Medical Education on Social Health Integration and Social Risk-Informed Care for Primary Care Providers.

INTRODUCTION: Adapting clinical care decisions for patient-reported social risks is essential to social health integration and patient-centered care. Most research in this area focuses on awareness and assistance (social-needs-targeted care), such as screening and referral to food, financial, and other resources. Limited evidence for adjustment strategies (social risk-informed care) or adapting care for social risks made it difficult for Kaiser Permanente to implement new initiatives. This article describes a codesign process to build a novel, adjustment-focused continuing medical education course. METHODS: The authors codeveloped the online continuing medical education course with patients and clinicians using user-centered design. Transcripts from codesign activities were coded and analyzed by thematic analysis to identify major themes, including perceptions of social risk-informed care and barriers to care adjustment. RESULTS: Practical hurdles for implementing social risk-informed care emerged, including clinicians' concerns about the ethics of adjustment as substandard care, particularly without robust assistance activities. However, patients expressed a desire for their care to be adapted to their social circumstances, to allow for more realistic care plans. DISCUSSION: Implementation barriers identified from the codesign were addressed through an interactive, case-study approach. Existing evidence on contextualized care and shared decision making informed a general framework for primary care providers to engage in awareness and adjustment activities, paired with 3 interactive case studies based on real-world, clinician-supplied scenarios. CONCLUSION: The authors recommend that multiple stakeholder perspectives be incorporated during the development of social health integration initiatives, particularly adjustment. Education complemented by active, nuanced, flexible implementation strategies may be necessary for the successful uptake of care-delivery-based social health integration activities.

Adaptation of a Tailored Lung Cancer Screening Decision Aid for People With HIV.

BACKGROUND: People with HIV are both at elevated risk of lung cancer and at high risk of multimorbidity, which makes shared decision-making (SDM) for lung cancer screening (LCS) in people with HIV complex. Currently no known tools have been adapted for SDM in people with HIV. RESEARCH QUESTION: Can an SDM decision aid be adapted to include HIV-specific measures with input from both people with HIV and their providers? STUDY DESIGN AND METHODS: This study used qualitative methods including focus groups of people with HIV and interviews with HIV care providers to adapt and iterate an SDM tool for people with HIV. Eligible participants were those with HIV enrolled in an HIV primary care clinic who met age and smoking eligibility criteria for LCS and HIV care providers at the clinic. Both the focus groups and interviews included semistructured discussions of SDM and decision aid elements for people with HIV. We used a framework-guided thematic analysis, mapping themes onto the Health Equity Implementation framework. RESULTS: Forty-three people with HIV participated in eight focus groups; 10 providers were interviewed. Key themes from patients included broad interest in adapting LCS SDM specifically for people with HIV, a preference for clear LCS recommendations, and the need for positive framing emphasizing survival. Providers were enthusiastic about personalized LCS risk assessments and point-of-care tools. Both patients and providers gave mixed views on the usefulness of HIV-specific risk measures in patient-facing tools. Themes were used to adapt a personalized and flexible SDM tool for LCS in people with HIV. INTERPRETATION: People with HIV and providers were enthusiastic about specific tools for SDM that are personalized and tailored for people with HIV, that make recommendations, and that inform LCS decision-making. Divergent views on presenting patient-facing quantitative risk assessments suggests that these elements could be optional but available for review. This tool may have usefulness in complex decision-making for LCS in this population and currently is being evaluated in a pilot prospective trial.

The Use of a Tailored Decision Aid to Improve Understanding of Lung Cancer Screening in People With HIV.

BACKGROUND: People with HIV are at increased risk for lung cancer and multimorbidity, complicating the balance of risks and benefits of lung cancer screening. We previously adapted Decision Precision (screenlc.com) to guide shared decision-making for lung cancer screening in people with HIV. RESEARCH QUESTION: Does an HIV-adapted and personally tailored decision aid improve shared decision-making regarding lung cancer screening in people with HIV as measured by knowledge, decisional conflict, and acceptability? STUDY DESIGN AND METHODS: This was a single-arm pilot trial of the decision aid in 40 participants with HIV eligible for lung cancer screening. The decision aid included personalized screening recommendations and HIV-specific, 5-year risk estimates of lung cancer and all-cause mortality. Participants reviewed the decision aid at shared decision-making visits and completed previsit and postvisit surveys with measures of knowledge about lung cancer screening, acceptability, and decisional conflict. RESULTS: The 40 enrolled participants were a median age of 62 years, 60% currently smoked, and they had median 5-year risks of lung cancer and all-cause mortality of 2.0% (IQR, 1.4%-3.3%) and 4.1% (IQR, 3.3%-7.9%), respectively. Personalized recommendations included "Encourage Screening" for 53% of participants and "Preference Sensitive" recommendations for the remainder. Participants showed improvement in two validated knowledge measures with relative improvement of 60% (P < 0.001) on the 12-question lung cancer screening knowledge test and 27% (P < .001) on the seven-question lung cancer screening knowledge score, with significant improvement on questions regarding false-positive and false-negative findings, incidental findings, lung cancer-specific mortality benefit, and the possible harms of screening. Participants reported low scores on the decisional conflict scale (median score, 0; interquartile range, 0-5) and high acceptability. Ninety percent of patients ultimately underwent screening within 1 month of the visit. INTERPRETATION: In our study, this HIV-adapted and personally tailored decision aid improved participants' knowledge of risks, benefits, and characteristics of screening with low decisional conflict and high acceptability. Our results indicate that this decision aid can enable high-quality shared decision-making in this high-risk population. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov; No.: NCT04682301; URL: www. CLINICALTRIALS: gov.

Understanding the Relationship Between Social Risk Factors and COVID-19 Contacts.

Introduction Social risks are associated with increased risk of COVID-19 transmission by limiting patients' ability to practice precautions and access care. Researchers need to understand the prevalence of patients' social risk factors during the pandemic and recognize how social risks may exacerbate COVID-19. Methods The authors conducted a national survey among Kaiser Permanente members between January and September 2020 and restricted analyses to those who responded to a set of COVID-19 items. The survey asked if they experienced social risks, knew of people with COVID-19, and if COVID-19 affected their emotional and mental health, and their preferred type of assistance. Results Social risks were reported by 62% of respondents, with 38% reporting having 2 or more social risks. Respondents most commonly reported financial strain (45%). One or more contact types with COVID-19 were reported by one-third of the respondents. Those with 2 or more COVID-19 contact types reported higher housing instability, financial strain, food insecurity, and social isolation than those with fewer contacts. Overall, 50% of respondents reported that COVID-19 negatively affected their emotional, mental health, and 19% noted that it affected their ability to maintain a job. Discussion People with any COVID-19 contacts reported more social risks compared to those who did not know anyone with COVID-19. This suggests that those with higher social risks during this time may have faced higher risk for COVID-19, or the converse may be true. Conclusion These findings highlight patients' social health during the pandemic and suggest that health systems develop interventions to assess social health and link patients to appropriate resources.

Kaiser Permanente's Social Needs Network for Evaluation and Translation Empirical Research Agenda.

Introduction: Healthcare systems such as Kaiser Permanente are increasingly focusing on patients' social health. However, there is limited evidence to guide social health integration strategy. The purpose of this study was to identify social health research opportunities using a stakeholder-driven process. Methods: A modified Concept Mapping approach was implemented from June 2021 to February 2022. Stakeholders (n=746) received the prompt, "One thing I wish we knew more about to advance my work addressing social health..." An inductive content analysis approach was used to assign topics and synthesize and refine research-focused statements into research questions. Questions were then rated on impact and priority by researcher stakeholders (n=16). Mean impact and priority scores and an overall combined score were calculated. Question rankings were generated using the combined score. Results: Brainstorming produced 148 research-focused statements. A final list of 59 research questions was generated for rating. Question topics were (1) Data, Measures, and Metrics; (2) Intervention Approach and Impact; (3) Technology; (4) Role of Healthcare Systems; (5) Community-Based Organizations; (6) Equity; (7) Funding; and (8) Social Health Integration. On a scale from 1 (low) to 10 (high), the mean impact score was 6.12 (range=4.14-7.79), and the mean priority score was 5.61 (range=3.07-8.64). Twenty-four statements were rated as both high impact (>6.12) and high priority (>5.61). Conclusions: The broad range of topics with high impact and priority scores reveals how nascent the evidence base is, with fundamental research on the nature of social risk and health system involvement still needed.

Lung Cancer Screening in People With HIV: A Mixed-Methods Study of Patient and Provider Perspectives.

INTRODUCTION: People with HIV are at higher risk of lung cancer; however, there is limited research on attitudes, barriers, and facilitators to lung cancer screening in people with HIV. The objective of this study was to understand the perspectives on lung cancer screening among people with HIV and their providers. METHODS: Surveys of people with HIV and HIV-care providers were complemented by qualitative focus groups and interviews designed to understand the determinants of lung cancer screening in people with HIV. Participants were recruited through an academic HIV clinic in Seattle, WA. Qualitative guides were developed by integrating the Consolidated Framework for Implementation Research and the Tailored Implementation of Chronic Diseases checklist. Themes that emerged from thematic analyses of qualitative data were compared with surveys in joint displays. All study components were conducted between 2021 and 2022. RESULTS: Sixty-four people with HIV completed surveys, and 43 participated in focus groups. Eleven providers completed surveys, and 10 were interviewed for the study. Themes from joint displays show overall enthusiasm for lung cancer screening among people with HIV and their providers, particularly with a tailored and evidence-based approach. Facilitators in this population may include longstanding engagement with providers and health systems and an emphasis on survivorship through preventive healthcare interventions. People with HIV may also face barriers acknowledged by providers, including a high level of medical comorbidities and competing issues such as substance abuse, mental health concerns, and economic instability. CONCLUSIONS: This study reveals that people with HIV and their providers have overall enthusiasm toward screening. However, tailored interventions may be needed to overcome specific barriers, including complex decision making in the setting of medical comorbidity and patient competing issues.

Advancing health equity through implementation science: Identifying and examining measures of the outer setting.

BACKGROUND: Implementation science (IS) could accelerate progress toward achieving health equity goals. However, the lack of attention to the outer setting where interventions are implemented limits applicability and generalizability of findings to different populations, settings, and time periods. We developed a data resource to assess outer setting across seven centers funded by the National Cancer Institute's IS Centers in Cancer Control (ISC3) Network Program. OBJECTIVE: To describe the development of the Outer Setting Data Resource and characterize the county-level outer context across Centers. METHODS: Our Data Resource captures seven key environments, including: (1) food; (2) physical; (3) economic; (4) social; (5) health care; (6) cancer behavioral and screening; and (7) cancer-related policy. Data were obtained from public sources including the US Census and American Community Survey. We present medians and interquartile ranges based on the distribution of all counties in the US, all ISC3 centers, and within each Center for twelve selected measures. Distributions of each factor are compared with the national estimate using single sample sign tests. RESULTS: ISC3 centers' catchment areas include 458 counties and over 126 million people across 28 states. The median percentage of population living within ½ mile of a park is higher in ISC3 counties (38.0%, interquartile range (IQR): 16.0%-59.0%) compared to nationally (18.0%, IQR: 7.0%-38.0%; p < 0.0001). The median percentage of households with no broadband access is significantly lower in ISC3 counties (28.4%, IQR: 21.4%-35.6%) compared the nation overall (32.8%, IQR: 25.8%-41.2%; p < 0.0001). The median unemployment rate was significantly higher in ISC3 counties (5.2%, IQR: 4.1%-6.4%) compared to nationally (4.9%, 3.6%-6.3%, p = 0.0006). CONCLUSIONS: Our results indicate that the outer setting varies across Centers and often differs from the national level. These findings demonstrate the importance of assessing the contextual environment in which interventions are implemented and suggest potential implications for intervention generalizability and scalability.

Partnerships to expand worksite wellness programs - A qualitative analysis of state and local health department perspectives.

Chronic diseases such as heart disease, cancer, and diabetes are the leading causes of death and disability in the U. S. Because the central mission of state and local health departments (HDs) is to protect, promote, and improve population health, these agencies are well-positioned to address risk behaviors for chronic disease. HD-employer partnerships could enhance worksite wellness programming, but few studies have explored this topic. Building upon previously published findings, the purpose of this qualitative study was to describe the context and environment for HDs' delivery of worksite wellness programs, including interest, barriers, facilitators, and decision-making processes. We conducted 12 interviews with directors of state chronic disease programs, 21 interviews with local directors, and three focus groups with local staff. We performed a thematic analysis of the data. Key themes include the following: (1) worksite wellness programs delivered by HDs were diverse in topic and scope and delivered both internally (at the HD for their agency) and externally (for other employers); (2) decisions made about chronic disease prevention were largely driven by funding priorities, with federal, state, and local entities playing roles in the decision-making process; and (3) HDs expressed potential interest in worksite wellness program delivery, dependent upon staff capacity, available funding, and employer buy-in. Our results suggest that funding should be increased for and reallocated towards chronic disease prevention, including worksite wellness. To overcome HD barriers to program delivery, key funders and stakeholders should prioritize and communicate the importance of worksite wellness.

Development of a Wellness Committee Implementation Index for Workplace Health Promotion Programs in Small Businesses.

PURPOSE: To construct a wellness committee (WC) implementation index and determine whether this index was associated with evidence-based intervention implementation in a workplace health promotion program. DESIGN: Secondary data analysis of the HealthLinks randomized controlled trial. SETTING: Small businesses assigned to the HealthLinks plus WC study arm. SAMPLE: Small businesses (20-200 employees, n = 23) from 6 low-wage industries in King County, Washington. MEASURES: Wellness committee implementation index (0%-100%) and evidence-based intervention implementation (0%-100%). ANALYSIS: We used descriptive and bivariate statistics to describe worksites' organizational characteristics. For the primary analyses, we used generalized estimating equations with robust standard errors to assess the association between WC implementation index and evidence-based intervention implementation over time. RESULTS: Average WC implementation index scores were 60% at 15 months and 38% at 24 months. Evidence-based intervention scores among worksites with WCs were 27% points higher at 15 months (64% vs 37%, P < .001) and 36% points higher at 24 months (55% vs 18%, P < .001). Higher WC implementation index scores were positively associated with evidence-based intervention implementation scores over time (P < .001). CONCLUSION: Wellness committees may play an essential role in supporting evidence-based intervention implementation among small businesses. Furthermore, the degree to which these WCs are engaged and have leadership support, a set plan or goals, and multilevel participation may influence evidence-based intervention implementation and maintenance over time.

Managers' Support for Employee Wellness Programs: An Integrative Review.

OBJECTIVE: The aim of this integrative literature review is to synthesize the existing evidence regarding managers' support for employee wellness programs. DATA SOURCE: The search utilized multiple electronic databases and libraries. STUDY INCLUSION AND EXCLUSION CRITERIA: Inclusion criteria comprised peer-reviewed research published in English, between 1990 and 2016, and examining managers' support in the context of a worksite intervention. The final sample included 21 articles for analysis. DATA EXTRACTION: Two researchers extracted and described results from each of the included articles using a content analysis. DATA SYNTHESIS: Two researchers independently rated the quality of the included articles. Researchers synthesized data into a summary table by study design, sample, data collected, key findings, and quality rating. RESULTS: Factors that may influence managers' support include their organization's management structure, senior leadership support, their expected roles, training on health topics, and their beliefs and attitudes toward wellness programs and employee health. Managers' support may influence the organizational culture, employees' perception of support, and employees' behaviors. CONCLUSIONS: When designing interventions, health promotion practitioners and researchers should consider strategies that target senior, middle, and line managers' support. Interventions need to include explicit measures of managers' support as part of the evaluation plan.