Promoting sustainable community change in support of older adult physical activity: evaluation findings from the Southeast Seattle Senior Physical Activity Network (SESPAN).

Researchers have identified as effective and worthy of broader dissemination a variety of intervention strategies to promote physical activity among older adults. This paper reports results of a community-organizing approach to disseminating evidence-based interventions in a sustainable way: The Southeast Seattle Senior Physical Activity Network (SESPAN). SESPAN was implemented in Southeast Seattle, a group of multicultural neighborhoods extending 8 miles southeast of downtown Seattle, with a population of 56,469 in 2000, with 12% (7,041) aged 65 and older. The SESPAN organizing strategy involved networking to: (1) make connections between two or more community organizations to create new senior physical activity programs; and (2) build coalitions of community groups and organizations to assist in making larger scale environmental and policy changes to increase senior physical activity. The SESPAN evaluation used an uncontrolled prospective design focusing on sustainable community changes, including new or modified programs, policies, and practices. Networking among organizations led to the creation of 16 ongoing exercise classes and walking groups, serving approximately 200 older adults in previously underserved Southeast Seattle communities. In addition, the project's health coalition is sustaining current activities and generating new programs and environmental changes. The success of the SESPAN organizing model depended on identifying and involving champions in partner organizations who provided support and resources for implementing programs.

A study of the diagnostic accuracy of the PHQ-9 in primary care elderly.

BACKGROUND: The diagnostic accuracy of the Patient Health Questionnaire-9 (PHQ-9) for assessment of depression in elderly persons in primary care settings in the United States has not been previously addressed. Thus, the purpose of this study was to evaluate the test performance of the PHQ-9 for detecting major and minor depression in elderly patients in primary care. METHODS: A prospective study of diagnostic accuracy was conducted in two primary care, university-based clinics in the Pacific Northwest of the United States. Seventy-one patients aged 65 years or older participated; all completed the PHQ-9 and the 15-item Geriatric Depression Scale (GDS) and underwent the Structured Clinical Interview for Depression (SCID). Sensitivity, specificity, area under the receiver operating characteristic (ROC) curve, and likelihood ratios (LRs) were calculated for the PHQ-9, the PHQ-2, and the 15-item GDS for major depression alone and the combination of major plus minor depression. RESULTS: Two thirds of participants were female, with a mean age of 78 and two chronic health conditions. Twelve percent met SCID criteria for major depression and 13% minor depression. The PHQ-9 had an area under the curve (AUC) of 0.87 (95% confidence interval [CI], 0.74-1.00) for major depression, while the PHQ-2 and the 15-item GDS each had an AUC of 0.81 (95% CI for PHQ-2, 0.64-0.98, and for 15-item GDS, 0.70-0.91; P = 0.551). For major and minor depression combined, the AUC for the PHQ-9 was 0.85 (95% CI, 0.73-0.96), for the PHQ-2, 0.80 (95% CI, 0.68-0.93), and for the 15-item GDS, 0.71 (95% CI, 0.55-0.87; P = 0.187). CONCLUSIONS: Based on AUC values, the PHQ-9 performs comparably to the PHQ-2 and the 15-item GDS in identifying depression among primary care elderly.

Evaluating a preventive services index to adjust for healthy behaviors in observational studies of older adults.

INTRODUCTION: Analysis of outcome measures from nonrandomized, observational studies of people participating or not participating in health programs may be suspect because of selection bias. For example, fitness programs may preferentially enroll people who are already committed to healthy lifestyles, including use of preventive services. Some of our earlier studies have attempted to account for this potential bias by including an ad hoc preventive services index created from the patient's number of earlier clinical preventive services, to adjust for health-seeking behaviors. However, this index has not been validated. We formally evaluated the performance of this preventive services index by comparing it with its component parts and with an alternative index derived from principal component analysis by using the weighted sums of the principal components. METHODS: We used data from a cohort of 38,046 older adults. We used the following variables from the administrative database of a health maintenance organization to create this index: fecal occult blood test, flexible sigmoidoscopy, screening mammogram, prostate cancer screening, influenza vaccination, pneumococcal vaccination, and preventive care office visits. RESULTS: The preventive services index was positively correlated with each of the following components: colon cancer screening (r = .752), screening mammogram (r = .559), prostate cancer screening (r = .592), influenza vaccination (r = .844), pneumococcal vaccination (r = .487), and preventive care office visits (r = .737). An alternative preventive services index, created by using principal component analysis, had similar performance. CONCLUSION: A preventive services index created by using administrative data has good face validity and construct validity and can be used to partially adjust for selection bias in observational studies of cost and use outcomes.

Health care costs and participation in a community-based health promotion program for older adults.

INTRODUCTION: EnhanceWellness (EW) is a community-based health promotion program that helps prevent disabilities and improves health and functioning in older adults. A previous randomized controlled trial demonstrated a decrease in inpatient use for EW participants but did not evaluate health care costs. We assessed the effect of EW participation on health care costs. METHODS: We performed a retrospective cohort study in King County, Washington. Enrollees in Group Health Cooperative (GHC), a mixed-model health maintenance organization, who were aged 65 years or older and who participated in EW from 1998 through 2005 were matched 1:3 by age and sex to GHC enrollees who did not participate in EW. We matched 218 EW participants by age and sex to 654 nonparticipants. Participants were evaluated for 1 year after the date they began the program. The primary outcome was total health care costs; secondary outcomes were inpatient costs, primary care costs, percentage of hospitalizations, and number of hospital days. We compared postintervention outcomes between EW participants and nonparticipants by using linear regression. Results were adjusted for prior year costs (or health care use), comorbidity, and preventive health care-seeking behaviors. RESULTS: Mean age of participants and nonparticipants was 79 years, and 72% of participants and nonparticipants were female. Adjusted total costs in the year following the index date were $582 lower among EW participants than nonparticipants, but this difference was not significant. CONCLUSION: Although EW participation demonstrated health benefits, participation does not appear to result in significant health care cost savings among people receiving health care through a health maintenance organization.

A community-organizing approach to promoting physical activity in older adults: the southeast senior physical activity network.

This article describes a community organizing approach to promoting physical activity among underserved older adults in southeast Seattle: the Southeast Senior Physical Activity Network (SESPAN). The organizing strategy involves networking with a variety of community-based organizations, with two broad objectives: (a) program objective-to make connections between two (or more) community-based organizations to create senior physical activity programs where none existed before; and (b) coalition objective-to build a broader network or coalition of groups and organizations to assist in making larger scale environmental and policy changes. Networking among organizations led to the creation of a number of potentially sustainable walking and exercise programs that are reaching previously underserved communities within Southeast Seattle. In addition, a major community event led to the establishment of a health coalition that has the potential to continue to generate new broad-based programs and larger scale environmental changes.

Can mHealth and eHealth improve management of diabetes and hypertension in a hard-to-reach population? -lessons learned from a process evaluation of digital health to support a peer educator model in Cambodia using the RE-AIM framework.

BACKGROUND: The burden of non-communicable diseases (NCDs) is increasing in low- and middle-income countries (LMICs) where NCDs cause 4:5 deaths, disproportionately affect poorer populations, and carry a large economic burden. Digital interventions can improve NCD management for these hard-to-reach populations with inadequate health systems and high cell-phone coverage; however, there is limited research on whether digital health is reaching this potential. We conducted a process evaluation to understand challenges and successes from a digital health intervention trial to support Cambodians living with NCDs in a peer educator (PE) program. METHODS: MoPoTsyo, a Cambodian non-governmental organization (NGO), trains people living with diabetes and/or hypertension as PEs to provide self-management education, support, and healthcare linkages for better care management among underserved populations. We partnered with MoPoTsyo and InSTEDD in 2016-2018 to test tailored and targeted mHealth mobile voice messages and eHealth tablets to facilitate NCD management and clinical-community linkages. This cluster randomized controlled trial (RCT) engaged 3,948 people and 75 PEs across rural and urban areas. Our mixed methods process evaluation was guided by RE-AIM to understand impact and real-world implications of digital health. Data included patient (20) and PE interviews (6), meeting notes, and administrative datasets. We triangulated and analyzed data using thematic analysis, and descriptive and complier average causal effects statistics (CACE). RESULTS: Reach: intervention participants were more urban (66% vs. 44%), had more PE visits (39 vs. 29), and lower uncontrolled hypertension [12% and 7% vs. 23% and 16% uncontrolled systolic blood pressure (SBP) and diastolic blood pressure (DBP)]. Adoption: patients were sent mean [standard deviation (SD)] 30 [14] and received 14 [8] messages; 40% received no messages due to frequent phone number changes. Effectiveness: CACE found clinically but not statistically significant improvements in blood pressure and sugar for mHealth participants who received at least one message vs. no messages. Implementation: main barriers were limited cellular access and that mHealth/eHealth could not solve structural barriers to NCD control faced by people in poverty. Maintenance: had the intervention been universally effective, it could be paid for from additional revolving drug fund revenue, new agreements with mobile networks, or the government. CONCLUSIONS: Evidence for digital health to improve NCD outcomes in LMICs are limited. This study suggests digital health alone is insufficient in countries with low resource health systems and that high cell phone coverage did not translate to access. Adding digital health to an NCD peer network may not significantly benefit an already effective program; mHealth may be better for hard-to-reach populations not connected to other supports. As long as mHealth remains an individual-level intervention, it will not address social determinants of health that drive outcomes. Future digital health research and practice to improve NCD management in LMICs requires engaging government, NGOs, and technology providers to work together to address barriers.

Utilization of diabetes management health care services and its association with glycemic control among patients participating in a peer educator-based program in Cambodia.

BACKGROUND: Substantial evidence supports the effectiveness of peer educator programs for diabetes management in low- and middle-income countries. However, little is known about peer educators' impact relative to other treatment components such as medication and physician consultation. In Cambodia, the non-governmental organization MoPoTsyo organizes four services for people with diabetes: self-management training through peer educator visits, lab tests, physician consultations, and low-cost medicines. Our aims were to 1) quantify MoPoTsyo participant utilization of each program service and 2) define the relationship between each program service and glycemic control. METHODS: We conducted a retrospective cohort study among 4,210 MoPoTsyo participants, using data collected by MoPoTsyo from 2006-2016. Independent variables assessed were medication adherence, number of peer educator visits, number of physician consultations, and number of lab tests. A multiple logistic regression model was used to evaluate the association between these disease management services and glycemic control-fasting plasma glucose ≤130 mg/dl or post-prandial glucose ≤180 mg/dl-based on most recent glucose level. The model was adjusted for baseline demographic and disease characteristics. FINDINGS: Participants with 12 or more peer educator visits per year had a 35% higher odds of glycemic control relative to participants with 4 or fewer visits (odds ratio 1.35, 95% CI: 1.08-1.69; p = 0.009), after adjustment for utilization of other treatment components (medication adherence, number of physician visits, number of lab tests), follow-up time, and demographic and disease characteristics. Better adherence to medications and a greater number of lab tests per year were also associated with a higher odds of glycemic control after adjustment. Number of physician consultations was not associated with glycemic control after adjustment. CONCLUSIONS: This study demonstrates a positive association between peer educator utilization and glycemic control incremental to other elements of diabetes management. These results suggest that peer educators may be a valuable addition to comprehensive diabetes management programs in low- and middle-income countries even when other health care services are accessible. The associations identified in this research warrant further prospective studies to explore the causal impact of peer educators on glycemic control relative to other disease management components.

Facilitators and Barriers to Chronic Disease Self-Management and Mobile Health Interventions for People Living With Diabetes and Hypertension in Cambodia: Qualitative Study.

BACKGROUND: In many low- and middle-income countries (LMICs), heart disease and stroke are the leading causes of death as cardiovascular risk factors such as diabetes and hypertension rapidly increase. The Cambodian nongovernmental organization, MoPoTsyo, trains local residents with diabetes to be peer educators (PEs) to deliver chronic disease self-management training and medications to 14,000 people with hypertension and/or diabetes in Cambodia. We collaborated with MoPoTsyo to develop a mobile-based messaging intervention (mobile health; mHealth) to link MoPoTsyo's database, PEs, pharmacies, clinics, and people living with diabetes and/or hypertension to improve adherence to evidence-based treatment guidelines. OBJECTIVE: This study aimed to understand the facilitators and barriers to chronic disease management and the acceptability, appropriateness, and feasibility of mHealth to support chronic disease management and strengthen community-clinical linkages to existing services. METHODS: We conducted an exploratory qualitative study using semistructured interviews and focus groups with PEs and people living with diabetes and/or hypertension. Interviews were recorded and conducted in Khmer script, transcribed and translated into the English language, and uploaded into Atlas.ti for analysis. We used a thematic analysis to identify key facilitators and barriers to disease management and opportunities for mHealth content and format. The information-motivation-behavioral model was used to guide data collection, analysis, and message development. RESULTS: We conducted six focus groups (N=59) and 11 interviews in one urban municipality and five rural operating districts from three provinces in October 2016. PE network participants desired mHealth to address barriers to chronic disease management through reminders about medications, laboratory tests and doctor's consultations, education on how to incorporate self-management into their daily lives, and support for obstacles to disease management. Participants preferred mobile-based voice messages to arrive at dinnertime for improved phone access and family support. They desired voice messages over texts to communicate trust and increase accessibility for persons with limited literacy, vision, and smartphone access. PEs shared similar views and perceived mHealth as acceptable and feasible for supporting their work. We developed 34 educational, supportive, and reminder mHealth messages based on these findings. CONCLUSIONS: These mHealth messages are currently being tested in a cluster randomized controlled trial (#1R21TW010160) to improve diabetes and hypertension control in Cambodia. This study has implications for practice and policies in Cambodia and other LMICs and low-resource US settings that are working to engage PEs and build community-clinical linkages to facilitate chronic disease management.

Secondary prevention of myocardial infarction with nonpharmacologic strategies in a Medicaid cohort.

BACKGROUND: The quality of health care after myocardial infarction (MI) may be lacking; in particular, guidelines for nonpharmacologic interventions (cardiac rehabilitation, smoking cessation) may receive insufficient priority. We identified gaps between secondary prevention guidelines and ambulatory care received by Medicaid enrollees after an MI. METHODS: MI survivors were selected by using 2004 Washington State Medicaid administrative claims. Deidentified data were abstracted for hospitalizations, ambulatory care, and prescriptions for 365 days after the MI. Cox regression analysis compared utilization of guideline-directed secondary prevention strategies with death and recurrent hospitalization. RESULTS: The sample size was 372. Fifty patients died during the year after the MI, and 144 were rehospitalized. Only 2 patients attended a cardiac rehabilitation program. Tobacco cessation counseling was associated with a 66% reduction in death, but only 72.6% of smokers were counseled. Less than half (45.4%) of patients saw a primary care provider within 90 days of their MI, and 7.5% never contacted a health care provider. Receiving regular primary care was associated with a decreased risk for death (hazard ratio, 0.91; 95% confidence interval, 0.84-0.97, P < .01). A protective trend was associated with care by a cardiologist, but only 21.5% received specialist care. CONCLUSION: Analysis of Medicaid claims data suggests rates of secondary prevention are less than optimal. To improve survival and reduce rehospitalization after an MI, policy changes (tobacco cessation benefits, expansion of rehabilitation programs), health care capacity (training, referral patterns, and coordination of care), and improvements to access (removing barriers, increasing facilities, targeting minority populations) could be implemented.

Using Targeted mHealth Messages to Address Hypertension and Diabetes Self-Management in Cambodia: Protocol for a Clustered Randomized Controlled Trial.

BACKGROUND: Hypertension and diabetes represent the first and third highest contributors to global disability. While mobile health (mHealth) messaging programs have rapidly increased in low- and middle-income countries (LMIC), adaptations for specific patient health needs is a new approach to manage chronic conditions. OBJECTIVE: The primary aim of this study is to develop and test an mHealth communication intervention using electronic data capture (by tablet) and voice messaging to improve hypertension and diabetes self-management in Cambodia. The secondary aim is to share results with the Cambodian Ministry of Health and development partners to inform health policy and develop strategies for hypertension and diabetes control. METHODS: The study design is a cluster randomized controlled clinical trial randomizing each of 75 Community peer educators (PEs), trained and coordinated by MoPoTsyo Patient Information Center in Phnom Penh, into one of 3 groups of 25 (approximately 60 patients each) to receive either tablet+messages, tablet only, or no intervention (control). The total sample within each group includes 25 clusters and approximately 1500 patients located in 7 Operational Districts in rural regions or urban slums in Cambodia. The interventions (groups 1 and 2) were compared with usual PE monitoring without the tablet or mHealth messaging interventions. Focus groups and informant interviews were conducted to develop messages according to specific themes-medications adherence, laboratory testing, physician visits, obesity, smoking, and general lifestyle issues. Using the data received at monthly PE monitoring meetings, patients will receive specific messages based on their individual health challenges. Following the intervention completion, clinical and process outcomes will be compared with baseline metrics between groups. RESULTS: PEs were randomized in July 2017, and the intervention was implemented in September 2017 through June 2018. Analyses are underway. CONCLUSIONS: This project is unique in its combination of electronic data transfer, which can be accessed immediately, with voice messages most relevant to individual patients' needs. Positive results will indicate the value of using targeted messaging in patient-specific, self-management issues to improve hypertension and diabetes control. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/11614.

A mixed-methods needs assessment of traumatic brain injury care in a low- and middle-income country setting: building neurocritical care capacity at two major hospitals in Cambodia.

OBJECTIVE: The high global burden of traumatic brain injury (TBI) disproportionately affects low- and middle-income countries (LMICs). These settings also have the greatest disparity in the availability of surgical care in general and neurosurgical care in particular. Recent focus has been placed on alleviating this surgical disparity. However, most capacity assessments are purely quantitative, and few focus on concomitantly assessing the complex healthcare system needs required to care for these patients. The objective of the present study was to use both quantitative and qualitative assessment data to establish a comprehensive approach to inform capacity-development initiatives for TBI care at two hospitals in an LMIC, Cambodia. METHODS: This mixed-methods study used 3 quantitative assessment tools: the World Health Organization Personnel, Infrastructure, Procedures, Equipment, Supplies (WHO PIPES) checklist, the neurosurgery-specific PIPES (NeuroPIPES) checklist, and the Neurocritical Care (NCC) checklist at two hospitals in Phnom Penh, Cambodia. Descriptive statistics were obtained for quantitative results. Qualitative semistructured interviews of physicians, nurses, and healthcare administrators were conducted by a single interviewer. Responses were analyzed using a thematic content analysis approach and coded to allow categorization under the PIPES framework. RESULTS: Of 35 healthcare providers approached, 29 (82.9%) participated in the surveys, including 19 physicians (65.5%) and 10 nurses (34.5%). The majority had fewer than 5 years of experience (51.7%), were male (n = 26, 89.7%), and were younger than 40 years of age (n = 25, 86.2%). For both hospitals, WHO PIPES scores were lowest in the equipment category. However, using the NCC checklist, both hospitals scored higher in equipment (81.2% and 62.7%) and infrastructure (78.6% and 69.6%; hospital 1 and 2, respectively) categories and lowest in the training/continuing education category (41.7% and 33.3%, hospital 1 and 2, respectively). Using the PIPES framework, analysis of the qualitative data obtained from interviews revealed a need for continuing educational initiatives for staff, increased surgical and critical care supplies and equipment, and infrastructure development. The analysis further elucidated barriers to care, such as challenges with time availability for experienced providers to educate incoming healthcare professionals, issues surrounding prehospital care, maintenance of donated supplies, and patient poverty. CONCLUSIONS: This mixed-methods study identified areas in supplies, equipment, and educational/training initiatives as areas for capacity development for TBI care in an LMIC such as Cambodia. This first application of the NCC checklist in an LMIC setting demonstrated limitations in its use in this setting. Concomitant qualitative assessments provided insight into barriers otherwise undetected in quantitative assessments.

Depression and use of a health plan-sponsored physical activity program by older adults.

BACKGROUND: The purpose of this study was to determine the associations between depression and the likelihood of enrollment in a health plan-sponsored physical activity program and pattern of program participation over 2 years; a secondary aim was to examine the association between participation dose and depression risk. There are no published studies on how depression influences participation in health plan-sponsored physical activity programs and how participation affects depression risk in older adults in nonresearch settings. METHODS: This study used administrative data from a Medicare Advantage plan. Participants (n=4766) were enrolled in the plan for at least 1 year prior to participating in the plan-sponsored health club benefit (Silver Sneakers). Controls were age- and gender-matched to participants (n=9035). Members were identified as having depression based on ICD-9-CM codes. Multivariate regression and generalized estimating equations models were used. Data were collected between 1998 and 2003 and analyzed in 2008. RESULTS: Members who had a history of depression were as likely to participate in Silver Sneakers as nondepressed members (OR: 1.03; 95% CI=0.89, 1.20; p=0.67). The risk of lapse in Silver Sneakers attendance was 28%-55% (p<0.05) higher for depressed participants during months 15-24. For nondepressed Silver Sneakers participants, attendance of at least 2 visits/week during Year 1 was significantly associated with lower risk of depression in Year 2 (OR=0.54; 95% CI=0.37, 0.79; p=0.002); a similar but statistically nonsignificant association was observed for previously depressed participants (OR=0.51; 95% CI=0.26, 1.02; p=0.06). CONCLUSIONS: While depressed older adults are as likely to enroll in a health plan-sponsored physical activity as nondepressed members, they were at higher risk of attendance lapses. Greater participation in the physical activity program was associated with lower depression risk.

Antidepressant use in nonmajor depression: secondary analysis of a program to encourage active, rewarding lives for seniors (PEARLS), a randomized controlled trial in older adults from 2000 to 2003.

BACKGROUND: It is estimated that major depressive disorder affects 0.9% of community-dwelling older adults in the United States. However, as many as 18% of older US adults reportedly suffer from depressive symptoms that do not necessarily fit the criteria for major depressive disorder (eg, dysthmia, minor depression). OBJECTIVES: The goals of this study were to describe patterns of antidepressant medication use in older adults with dysthymia or minor depression and to examine factors associated with the use of antidepressants at baseline. METHODS: This was a secondary analysis using cross-sectional data collected during a randomized controlled trial conducted from 2000 through 2003. It involved community senior service agencies and in-home visits in Seattle, Washington. Adults aged >or=60 years who had minor depression or dysthymia and were receiving services through community senior service agencies or living in senior public housing were included. Study participants were classified as users or nonusers of antidepressants. Prescription medication use in the past 2 weeks was assessed at baseline and 6 and 12 months. Medication name, dose, and directions were recorded from the medication label. Logistic regression was used to examine variables associated with baseline antidepressant use. RESULTS: A total of 138 patients (mean age, 73.00 years) were included; the majority of study participants were female (779.00%). Overall, 42.33% were nonwhite (34.3% black, 4.4% Asian, 1.5% American Indian/Alaskan Native, 0.7% Hispanic, and 1.5% other). At baseline, 36.2% of study participants (n = 50) were using antidepressants. Selective serotonin reuptake inhibitors were the most common class of antidepressants, used by 62.00%, 70.22%, and 71.11% of antidepressant users at baseline, 6, and 12 months, respectively. However, nortriptyline was the most common antidepressant at baseline, taken by 20.00% of antidepressant users. Use of other prescription medications was associated with antidepressant use at baseline. CONCLUSIONS: We found antidepressant use to be low in these relatively poor, community-dwelling, ethnically diverse older adults with dysthymia and minor depression in 2000 through 2003, with 36.22% of participants using antidepressants at baseline. Antidepressant users were more likely to be taking other prescription medications than nonusers.

Translating a community-based motivational support program to increase physical activity among older adults with diabetes at community clinics: a pilot study of Physical Activity for a Lifetime of Success (PALS).

BACKGROUND: Regular physical activity is an important goal for elders with chronic health conditions. CONTEXT: This report describes Physical Activity for a Lifetime of Success (PALS), an attempt to translate a motivational support program for physical activity, Active Choices, for use by a group of diverse, low-income, community-dwelling elders with diabetes. METHODS: PALS linked physical activity assessment and brief counseling by primary care providers with a structured referral to a community-based motivational telephone support program delivered by older adult volunteers. People with diabetes aged 65 years or older who were receiving care at two community clinics were randomized to receive either immediate or delayed intervention. The main intended outcome measure was physical activity level; the secondary outcome measure was mean hemoglobin A1c. CONSEQUENCES: One-third of those offered referral to the PALS program in the clinic setting declined. Another 44% subsequently declined enrollment or were unreachable by the support center. Only 14 (21%) of those offered referral enrolled in the program. Among these 14, the percentage who were sufficiently active was higher at follow-up than at enrollment, though not significantly so. Using an intent-to-treat analysis, which included all randomized clinic patients, we found no significant change in mean hemoglobin A1c for the intervention group compared with controls. INTERPRETATION: A community-based referral and support program to increase physical activity among elderly, ethnically diverse, low-income people with diabetes, many of whom are not English-speaking, may be thwarted by unforeseen barriers. Those who enroll and participate in the PALS program appear to increase their level of physical activity.

Developing a Telephone Assessment of Physical Activity (TAPA) questionnaire for older adults.

INTRODUCTION: We report on development and preliminary validation of a brief, telephone-based measurement tool for assessing physical activity in older adults. The Telephone Assessment of Physical Activity (TAPA) questionnaire is based on the University of Washington Health Promotion Research Center's Rapid Assessment of Physical Activity (RAPA), a written questionnaire. METHODS: The Rapid Assessment of Physical Activity questionnaire was modified to permit interviewers to administer it as a telephone interview. We retained its scoring levels and interpretation. The pilot test of the telephone version assessed the questionnaire's ease of administration and construct validity in a community-based sample of older adults. Spearman rho and kappa statistics were computed for comparison with the Rapid Assessment of Physical Activity questionnaire and the Community Healthy Activities Model Program for Seniors questionnaire. RESULTS: Thirty-four older adults completed the telephone assessment. A Spearman rho of 0.74 and a kappa statistic of 0.48 were found between TAPA and the written RAPA. CONCLUSION: The pilot test demonstrated that the TAPA questionnaire is a promising instrument for use as a brief, telephone-based questionnaire for assessing physical activity in older adults.

Managed-Medicare health club benefit and reduced health care costs among older adults.

INTRODUCTION: Our study was undertaken to determine the association between use of a health plan-sponsored health club benefit by older adults and total health care costs over 2 years. METHODS: This retrospective cohort study used administrative and claims data from a Medicare Advantage plan. Participants (n = 4766) were enrolled in the plan for at least 1 year before participating in the plan-sponsored health club benefit (Silver Sneakers). Controls (n = 9035) were matched to participants by age and sex according to the index date of Silver Sneakers enrollment. Multivariate regression models were used to estimate health care use and costs and to make subgroup comparisons according to frequency of health club visits. RESULTS: Compared with controls, Silver Sneakers participants were older and more likely to be male, used more preventive services, and had higher total health care costs at baseline. Adjusted total health care costs for Silver Sneakers participants and controls did not differ significantly in year 1. By year 2, compared with controls, Silver Sneakers participants had significantly fewer inpatient admissions (-2.3%, 95% confidence interval, -3.3% to -1.2%; P < .001) and lower total health care costs (-$500; 95% confidence interval, -$892 to -$106; P = .01]. Silver Sneakers participants who averaged at least two health club visits per week over 2 years incurred at least $1252 (95% confidence interval, -$1937 to -$567; P < .001) less in health care costs in year 2 than did those who visited on average less than once per week. CONCLUSION: Regular use of a health club benefit was associated with slower growth in total health care costs in the long term but not in the short term. These findings warrant additional prospective investigations to determine whether policies to offer health club benefits and promote physical activity among older adults can reduce increases in health care costs.

Impact of a managed-Medicare physical activity benefit on health care utilization and costs in older adults with diabetes.

OBJECTIVE: The purpose of this article was to determine the effects of a managed-Medicare physical activity benefit on health care utilization and costs among older adults with diabetes. RESEARCH DESIGN AND METHODS: This retrospective cohort study used administrative and claims data for 527 patients from a diabetes registry of a staff model HMO. Participants (n = 163) were enrolled in the HMO for at least 1 year before joining the Enhanced Fitness Program (EFP), a community-based physical activity program for which the HMO pays for each EFP class attended. Control subjects were matched to participants according to the index date of EFP enrollment (n = 364). Multivariate regression models were used to determine 12-month postindex differences in health care use and costs between participants and control subjects while adjusting for age, sex, chronic disease burden, EFP attendance, prevention score, heart registry, and respective baseline use and costs. RESULTS: Participants and control subjects were similar at baseline with respect to age (75 +/- 5.5 years), A1C levels (7.4 +/- 1.4%), chronic disease burden, prevention score, and health care use and costs. After exposure to the program, there was a trend toward lower hospital admissions in EFP participants compared with control subjects (13.5 vs. 20.9%, P = 0.08), whereas total health care costs were not different (P = 0.39). EFP participants who attended > or = 1 exercise session/week on average had approximately 41% less total health care costs compared with those attending <1 session/week (P = 0.03) and with control subjects (P = 0.02). CONCLUSIONS: Although elective participation in a community-based physical activity benefit at any level was not associated with lower inpatient or total health care costs, greater participation in the program may lower health care costs. These findings warrant additional investigations to determine whether policies to offer and promote a community-based physical activity benefit in older adults with diabetes can reduce health care costs.

Barriers and facilitators of diabetes services in Nepal: a qualitative evaluation.

For the past three decades, the burden of diabetes in Nepal has been steadily increasing, with an estimated 3% annual increase since the year 2000. Although the burden is increasing, the methods of addressing the challenge have remained largely unchanged. This study sought to assess the current state of diabetes services provided by health facilities and to identify the major barriers that people with diabetes commonly face in Nepal. For this qualitative study, we selected five health facilities of varying levels and locations. At each site, we employed three unique methods: a process evaluation of the diabetes treatment and prevention services available, in-depth interviews with patients and focus group discussions with community members without diabetes. We used thematic analysis to analyse the data. Our findings were organized into the five categories of the Ecological Model: Individual, Interpersonal, Organizational, Community and Public Policy. Sub-optimal knowledge and behaviors of patients often contributed to poor diabetes management, especially related to diet control, physical activity and initiation of drug treatment. Social support was often lacking. Organizational challenges included health provider shortages, long wait times, high patient loads and minimal time available to spend with patients, often resulting in incomprehensive care. Public policy challenges include limited services in rural settings and financial burden. The scarcity of financial and human resources for health in Nepal often results in the inability of the current healthcare system to provide comprehensive prevention and management services for chronic diseases. A multilevel, coordinated approach is necessary to address these concerns. In the short-term, adding community-based supplementary solutions outside of the traditional hospital-based model could help to increase access to affordable services.

Correction: Evaluation of a multi-faceted diabetes care program including community-based peer educators in Takeo province, Cambodia, 2007-2013.

[This corrects the article DOI: 10.1371/journal.pone.0181582.].

Barriers and facilitators to treatment among patients with newly diagnosed hypertension in Nepal.

OBJECTIVE: Hypertension is a significant and rising burden in Nepal. The disease remains undetected and inadequately managed. However, no studies have been conducted to understand the inhibiting and facilitating factors to hypertension treatment among newly diagnosed cases. This qualitative study aimed to explore barriers and facilitators to treatment among patients with newly diagnosed hypertension aged ≥18 years in Dhulikhel, Nepal. METHODS: We conducted seven focus group discussions with 35 patients with newly diagnosed hypertension identified through community surveillance of the Dhulikhel Heart Study, an observational cohort of Dhulikhel Hospital, Kathmandu University. Audiotaped discussions were transcribed, inductively coded and analysed by the thematic framework method using Atlas.ti V.7. RESULTS: Hypertension was viewed as a rising problem in the community. Participants had limited knowledge and many misbeliefs regarding hypertension and its treatment. The major barriers included absence of symptoms, reluctance to take medicine, low perceived seriousness of the disease, challenges in behaviour change (diet and exercise), lack of family support, and lack of communication and trust with the provider. The major reported facilitating factors were fear of consequences of the disease, and family support in controlling diet and adhering to treatment. CONCLUSIONS: A number of factors emerged as barriers and facilitators to hypertension treatment. This information can be useful in designing appropriate health interventions to improve hypertension management.