Measurement properties of a novel survey to assess stages of organizational readiness for evidence-based interventions in community chronic disease prevention settings.

BACKGROUND: There is a great deal of variation in the existing capacity of primary prevention programs and policies addressing chronic disease to deliver evidence-based interventions (EBIs). In order to develop and evaluate implementation strategies that are tailored to the appropriate level of capacity, there is a need for an easy-to-administer tool to stage organizational readiness for EBIs. METHODS: Based on theoretical frameworks, including Rogers' Diffusion of Innovations, we developed a survey instrument to measure four domains representing stages of readiness for EBI: awareness, adoption, implementation, and maintenance. A separate scale representing organizational climate as a potential mediator of readiness for EBIs was also included in the survey. Twenty-three questions comprised the four domains, with four to nine items each, using a seven-point response scale. Representatives from obesity, asthma, diabetes, and tobacco prevention programs serving diverse populations in the United States were surveyed (N=243); test-retest reliability was assessed with 92 respondents. RESULTS: Confirmatory factor analysis (CFA) was used to test and refine readiness scales. Test-retest reliability of the readiness scales, as measured by intraclass correlation, ranged from 0.47-0.71. CFA found good fit for the five-item adoption and implementation scales and resulted in revisions of the awareness and maintenance scales. The awareness scale was split into two two-item scales, representing community and agency awareness. The maintenance scale was split into five- and four-item scales, representing infrastructural maintenance and evaluation maintenance, respectively. Internal reliability of scales (Cronbach's α) ranged from 0.66-0.78. The model for the final revised scales approached good fit, with most factor loadings >0.6 and all >0.4. CONCLUSIONS: The lack of adequate measurement tools hinders progress in dissemination and implementation research. These preliminary results help fill this gap by describing the reliability and measurement properties of a theory-based tool; the short, user-friendly instrument may be useful to researchers and practitioners seeking to assess organizational readiness for EBIs across a variety of chronic disease prevention programs and settings.

Contextual factors influencing readiness for dissemination of obesity prevention programs and policies.

Within the realm of obesity prevention research, there have been many promising interventions to improve physical activity and nutrition among diverse target populations. However, very little information is known about the dissemination and replication of these interventions. In 2007 and 2008 as part of a larger obesity prevention initiative, Missouri Foundation for Health funded 19 community-based programs throughout the state that showed promise of being model practices and committed to promoting their dissemination. Semi-structured key informant interviews were conducted with 64 individuals across the grant sites to help stage their readiness for dissemination. Through these interviews, the project team was able to identify the variables that impact a program's readiness for widespread distribution. Some factors contributing to readiness include: strong intervention planning and an existing sustainability plan; physical space available for the intervention; staff and monetary resources; administrative buy-in; community buy-in and engagement; a strong partner base and an agency with a healthy and active mission. These findings add to the literature by systematically identifying a set of key contextual variables. The qualitative data collected support a proposed framework and helps to establish a process for maintaining successful interventions based on several important factors that impact dissemination.

Evaluation of a digitally integrated accelerometer-based activity monitor for the measurement of activity in cats.

OBJECTIVE: To assess the correlation between data generated by an accelerometer-based activity monitor and the distance moved in cats. STUDY DESIGN: Prospective experimental study. ANIMALS: Three, four-year-old, male, purpose-bred research cats, weighing between 5.1 and 5.9 kg. METHODS: Part I: Collar and harness mounted accelerometers were evaluated in three cats, comparing simultaneously collected accelerometer data with movement data from computer-analyzed video. Part II: Cats wore collar and harness mounted accelerometers, and data were recorded for 4 weeks to evaluate day-to-day and week-to-week variation in activity. RESULTS: Part I: 432 hours of simultaneous video and accelerometer data were collected. The correlation between accelerometer counts and distance moved was 0.82 overall. Agreement between collar and harness mounted accelerometers was excellent with only 6% of the differences in measurements lying outside the mean difference +/- 2 standard deviations. The adjusted R(2) for harness accelerometer output and 6% mobility was 0.75; for movement 0.84; and for mean velocity 0.83. Evaluation of video indicated eating, grooming and scratching created high accelerometer counts with little effect on movement. Part II: There was a significant effect of day on harness (p < 0.001) and collar (p < 0.002) counts, with counts being lowest at the weekend. There was a significant effect of week on harness-mounted accelerometer counts (p < 0.034), but not on collar-mounted accelerometer counts. Harness accelerometer counts were lowest in week 1. CONCLUSION: Output from an acceleration-based digitally integrated accelerometer correlated well with distance moved and mobility in freely moving cats provided the mobility threshold in the analysis software was > or = 6%. CLINICAL RELEVANCE: Acceleration-based activity monitors may allow for objective measurement of improved mobility following analgesic treatment for conditions such as osteoarthritis.

Case study: contrasting challenges of insulin pump therapy in a toddler and adolescent with type 1 diabetes.

PURPOSE: To describe the challenges and outcomes of continuous subcutaneous insulin infusion (CSII) pump therapy in a toddler and adolescent with type 1 diabetes. Insight into patient-family aspects motivating pump use is provided. METHODS: Two cases treated at the Pediatric Diabetes Clinic at Yale University. RESULTS: Upon parental request, CSII was initiated to improve glycemic control in a 4-year-old boy (case 1) with unpredictable food intake. During 68 months of CSII therapy, hemoglobin A1C levels averaged 6.3% +/- 0.6%. Severe hypoglycemic episodes ceased 36 months ago, and occasional postprandial hyperglycemia during early school years was corrected with school nurses' reminders about premeal insulin bolus doses. Currently 9.5 years old, he independently manages all his insulin injections with parental assistance only to change the catheter site. Case 2 is a girl who was nearly 12 years of age when diagnosed with type 1 diabetes. Initially managed with daily injections, hypoglycemic episodes were interfering with her physically active lifestyle. At age 13 years, she elected CSII therapy, and glycemic control improved. Temporarily erratic in the immediate period pre- and postmenarche, metabolic control has since stabilized. At 15 years old, she successfully manages her diabetes independently. CONCLUSIONS: To optimize glycemic control, CSII can be initiated and used effectively, both in children of all ages and in adolescents with type 1 diabetes. CSII may be ideal therapy for toddlers, with no apparent lower age boundary for initiating CSII; however, the parenting challenges and requirements for supportive education differ between toddlers and adolescents. When disease and pump management are appropriately individualized, CSII therapy can help children with diabetes achieve and sustain glycemic control. Lifestyle flexibility, quality-of-life improvement, and independence can thus begin early in childhood and be maintained throughout young adulthood.

Analysis of continuous glucose monitoring data from non-diabetic and diabetic children: a tale of two algorithms.

Use of the Medtronic MiniMed Continuous Glucose Monitoring System (CGMS) in non-diabetic children has revealed many low and high sensor glucose (SG) values, suggesting that the original analytical algorithm (Solutions 2.0) might be overreading glycemic excursions. A revised algorithm (Solutions 3.0) was introduced in 2001. Our aim was to compare analyses of the same sensor profiles using both programs. Twenty-five lean, non-diabetic subjects (mean age 14 +/- 4 years) underwent continuous glucose monitoring with CGMS for up to 72 h. Sensor tracings were analyzed with both algorithms and compared. Separate analyses were performed for nocturnal readings (12-6 a.m.). Mean SG values were similar (103 +/- 24 mg/dL for version 2.0 vs. 100 +/- 14 for version 3.0), but the distribution was significantly different: 13.8% of total SG were <70 mg/dL by version 2.0 versus 8.2% by version 3.0 (p < 0.001), and 7.7% of total SG were >150 mg/dL by version 2.0 versus 4.7% by version 3.0 (p = 0.02). Of nocturnal SG values, 25.8% were <70 mg/dL by version 2.0 compared with 17.9% by version 3.0, and 9.4% were >150 mg/dL by version 2.0 compared with 4.0% by version 3.0. In lean non-diabetic children, Solutions 2.0 identified significantly more hypoglycemia and hyperglycemia than Solutions 3.0. Similar analyses in 40 children with type 1 diabetes revealed no significant differences. Solutions 3.0 may be a more useful algorithm for preventing over-reading of low and high SG readings in non-diabetic children, whereas both algorithms give similar results in children with diabetes.

Insulin pump therapy in pediatrics: a therapeutic alternative to safely lower HbA1c levels across all age groups.

OBJECTIVE: To examine the efficacy and safety of using continuous subcutaneous insulin infusion (CSII) therapy in a large group of patients 18 months to 18 yr from a single pediatric diabetes program. RESEARCH DESIGN AND METHODS: All patients < or = 18 yr of age starting on CSII from 1 January 1997 to 31 March 2000 at the Yale Children's Diabetes Program were included. Clinical data were collected prospectively before and during pump treatment. HbA1c was the primary efficacy outcome and rates of diabetes-related adverse events were the primary safety measures. RESULTS: One hundred and sixty-one children ranging in age from 18 months to 18 yr received CSII for an average of 32 +/- 9 months when data collection was closed on 31 October 2001, including 26 preschoolers (< 7 yr), 76 school-agers (7-11 yr) and 59 adolescents (12-18 yr). Mean HbA1c levels were 7.1% in the preschoolers, 7.8% in the school-agers and 8.1% in the adolescents prior to the start of CSII. There was a significant and consistent reduction in mean HbA1c levels after 12 months of CSII (to 6.5% in preschoolers, 7.3% in school-agers and 7.4% in adolescents, p < 0.02 vs. prepump) that was maintained at the most recent visit. Improved diabetes control was achieved with CSII without increasing daily insulin doses and in association with a decrease in the frequency of severe hypoglycemic events (p < 0.05 vs. prepump, all three age groups combined). CONCLUSIONS: CSII is an effective alternative to injection therapy in a large pediatric diabetes clinic setting. Even very young patients can utilize CSII to safely lower HbA1c levels.