An expanded chronic care management approach to multiple chronic conditions in Hispanics using community health workers as community extenders in the Rio Grande Valley of Texas.

INTRODUCTION: The synergistic negative effects of type 2 diabetes (T2DM) and hypertension increases all-cause mortality and the medical complexity of management, which disproportionately impact Hispanics who face barriers to healthcare access. The Salud y Vida intervention was delivered to Hispanic adults living along the Texas-Mexico Border with comorbid poorly controlled T2DM and hypertension. The Salud y Vida multicomponent intervention incorporated community health workers (CHWs) into an expanded chronic care management model to deliver home-based follow-up visits and provided community-based diabetes self-management education. METHODS: We conducted multivariable longitudinal analysis to examine the longitudinal intervention effect on reducing systolic and diastolic blood pressure among 3806 participants enrolled between 2013 and 2019. Participants were compared according to their program participation as either higher (≥ 10 combined educational classes and CHW visits) or lower engagement (<10 encounters). Data was collected between 2013 and 2020. RESULTS: Baseline mean systolic and diastolic blood pressure were 138 and 81 mmHg respectively. There were overall improvements in systolic (-6.49; 95% CI = [-7.13, -5.85]; p < 0.001) and diastolic blood pressure (-3.97; 95% CI = [-4.37, -3.56]; p < 0.001). The higher engagement group had greater systolic blood pressure reduction at 3 months (adjusted mean difference = -1.8 mmHg; 95% CI = [-3.2, -0.3]; p = 0.016) and at 15 month follow-up (adjusted mean difference = -2.3 mmHg; 95% CI = [-4.2, -0.39]; p = 0.0225) compared to the lower engagement group. CONCLUSION: This intervention, tested and delivered in a real-world setting, provides an example of how CHW integration into an expanded chronic care model can improve blood pressure outcomes for individuals with co-morbidities.

Influence of parental nativity and perceived neighborhood environment on physical activity and screen time of United States youth.

OBJECTIVE: This study assessed how parental nativity and perceived environment are associated with physical activity and screen time of U.S. children and adolescents. METHODS: Data originated from the 2020-21 U.S. National Survey of Children's Health. We conducted multivariable Poisson regression to assess the cross-sectional association of parental nativity and perceived neighborhood environment variables on parental reports of youth meeting national physical activity and screen time guidelines. We tested interactions of parental nativity and neighborhood environment variables on both outcomes. Analyses were conducted using STATA v17 and p < 0.05 indicated statistical significance. RESULTS: The sample of 24,928 children and 30,951 adolescents was 11.6 years of age, on average, with approximately 39% under 200% of the federal poverty level. About one-third of the sample (27.5%) had foreign-born parents. In adjusted models, we found that compared to youth with U.S.-born parents, those with foreign-born parents had a lower prevalence of meeting physical activity guidelines. Youth whose parents reported living in safe neighborhoods had a higher prevalence of meeting guidelines for physical activity (children: PR = 1.20, 95%CI 1.14, 1.27; adolescents: PR = 1.23, 95%CI 1.14, 1.32) and screen time (children: PR = 1.19, 95%CI 1.13, 1.26; adolescents: PR = 1.16, 95%CI 1.06, 1.28) than youth whose parents reported unsafe neighborhoods. We found similar associations between neighborhoods considered supportive or with many amenities and meeting physical activity and screen time guidelines. CONCLUSIONS: Youth whose parents are foreign-born have a lower prevalence of sufficient activity, and perceived parental neighborhood safety and support may be significant influences on youth physical activity and screen time.

Pilot Study to Assess the Effectiveness of the Sustainable Culturally Adaptive Nutrition Program (SCAN) to Improve Adherence to the National Diabetes Prevention Program.

PURPOSE: The Sustainable Culturally Adapted Nutrition Program (SCAN) is a novel adaptation to the National Diabetes Prevention Program (NDPP) that aims to improve attendance and effectiveness. This paper presents its feasibility and impact through the initial 6-month outcomes. DESIGN: A pragmatic quasi-experimental pilot study with intervention (DPP plus SCAN) and control (DPP only) groups. SAMPLES AND INCLUSION CRITERIA: Sustainable Culturally Adapted Nutrition Program participants were recruited from federally qualified health center (FQHC) clinic patients enrolled in a NDPP in Houston, Texas. Participants needed to be (1) ≥18 years old, (2) body mass index >25, (3) no prior diagnosis of diabetes, and (4) not pregnant. INTERVENTION: Sustainable Culturally Adapted Nutrition Program cooking classes were designed to teach skills to prepare fresh produce, and utilized Motivational Interviewing (MI) techniques to encourage participants to adapt these skills for foods that were culturally important to them. OUTCOME MEASURES: (1) National Diabetes Prevention Program attendance, (2) BMI and (3) percent weight loss. ANALYSIS: We used linear mixed models to test the association between weights and NDPP attendance. RESULTS: 22 intervention and 15 control participants completed the program to the 6-month point. Intervention participants had increased DPP attendance over controls (7.14 vs 6.87 session). Intervention participants also demonstrated on average, 1.5% weight loss for each additional SCAN class attended (P = .144). CONCLUSIONS: The SCAN adaptation shows promising results for effectively increasing both NDPP attendance and weight loss.

Exploration of Latina/Hispanic women's experiences living with non-alcoholic fatty liver disease: a qualitative study with patients in Houston.

OBJECTIVES: A deeper understanding of the lived experiences of Hispanic patients with non-alcoholic fatty liver disease (NAFLD) can help guide the development of behavioural programmes that facilitate NAFLD management. This paper explores Hispanic women's experiences living with NAFLD. DESIGN, SETTING, PARTICIPANTS: We collected brief sociodemographic questionnaires and conducted in-depth interviews with 12 low-income (all had household income ≤USD$55 000 per year) Hispanic women with NAFLD from the Houston area. Transcripts were audio-recorded and transcribed. We developed a coding scheme and used thematic analysis to identify emergent themes, supported by Atlas.ti. RESULTS: Participants identified physicians as their main information source on NAFLD but also consulted the internet, family, friends and peers. Many were still left wanting more information. Participants identified family history, sedentary lifestyles, poor diet and comorbid conditions as causes for their NAFLD. Participants also reported emotional distress after diagnosis. Participants experienced both successes and challenges in making lifestyle changes in nutrition and physical activity. Some participants received desired social support in managing NAFLD, although there were conflicting feelings about spousal support. CONCLUSION: Multifaceted programming that improves patient-provider communication, conveys accurate information and enhances social support is needed to support Hispanic women in managing NAFLD.

Understanding Primary Care Physician Perspectives on the Diagnosis and Management of Non-Alcoholic Fatty Liver Disease: A Qualitative Study.

Primary care physicians (PCPs) are well suited to manage patients with non-alcoholic fatty liver disease (NAFLD), but the limited, existing research suggests inadequate knowledge about the natural history, diagnostic methods, and management of NAFLD. The purpose of this qualitative study is to further understand the knowledge and practices for the diagnosis and management of NAFLD among PCPs. We conducted in-depth interviews with PCPs in the Greater Houston area, addressing current clinical practices used for diagnosing and managing NAFLD, as well as the perceptions of the PCPs regarding the burden of NAFLD on patients. We recorded interviews, transcribed them, coded transcripts, and identified patterns and themes. The interviewed PCPs (n = 16) were from internal or family medicine, with a range of experience (1.5-30 years). We found variations in NAFLD diagnosis and management across practices and by insurance status. Patients with abnormal liver imaging who had insurance or were within a safety-net healthcare system were referred by PCPs to specialists. Uninsured patients with persistently elevated liver enzymes received lifestyle recommendations from PCPs without confirmatory imaging or specialist referral. The role of PCPs in NAFLD management varied, with some helping patients set dietary and physical activity goals while others provided only general recommendations and/or referred patients to a dietitian. The diagnosis and management of NAFLD vary widely among PCPs and may be impacted by patients' insurance status and clinic-specific practices. The increasing burden of NAFLD in the U.S. medical system highlights the need for more PCPs involvement in managing NAFLD.

Development of a Culinary Medicine Toolkit to Improve Implementation of Virtual Cooking Classes for Low-Income Adults with Type 2 Diabetes.

Culinary medicine (CM) addresses diseases through nutrition and culinary education. To promote access to educational material for people with diabetes and engagement in virtual classes, we created a virtual culinary medicine toolkit (VCMT) sensitive to literacy levels and language preferences. The VCMT was developed to accompany existing virtual CM programs and help improve participant interaction and retention, offering educational materials for providers and participants. The provider VCMT offers level-setting education to reduce mixed nutrition messaging, including educational resources discussing inclusive nutrition and mindful eating topics. Each handout has a QR code and link to engaging, animated videos that provide further explanation. The participant VCMT offers a range of fundamental cooking skill videos and infographics, including knife skills and preparing whole grains and healthy beverages. Participant handouts and animated videos, which are played during the virtual CM class, allow participants to learn more about diabetes management and food literacy topics, including interpreting nutrition labels, and are employed during a CM to facilitate discussion and reflection. The animated videos replace a traditional slide-based lecture, allowing space for patient-centered facilitated discussions during virtual cooking sessions. The VCMT could guide the development of virtual CM interventions to shift learning from lecture-based to patient-centered discussions via a visual and inclusive medium.

Using the R = MC2 heuristic to understand barriers to and facilitators of implementing school-based physical activity opportunities: a qualitative study.

BACKGROUND: Schools are a key setting for supporting youth physical activity, given their broad reach and diverse student populations. Organizational readiness is a precursor to the successful implementation of school-based physical activity opportunities. The R = MC2 heuristic (Readiness = Motivation x Innovation-Specific Capacity x General Capacity) describes readiness as a function of an organization's motivation and capacity to implement an innovation and can be applied to better understand the implementation process. The purpose of this study was to explore the barriers to and facilitators of implementing school-based physical activity opportunities in the context of organizational readiness. METHODS: We analyzed interview data from 15 elementary school staff (principals, assistant principals, physical education teachers, and classroom teachers) from a school district in Texas. We focused on factors related to adopting, implementing, and sustaining a variety of school-based physical activity opportunities. We used the Framework Method to guide the analysis and coded data using deductive (informed by the R = MC2 heuristic) and inductive approaches. Themes were generated using the frequency, depth, and richness of participant responses. RESULTS: Four themes emerged from the data: (1) implementation is aided by the presence of internal and external relationships; (2) physical activity opportunities compete with other school priorities; (3) seeing the benefits of physical activity opportunities motivates school staff toward implementation; and (4) staff buy-in is critical to the implementation process. Themes 1-3 aligned with subcomponents of the R = MC2 heuristic (intra- and inter-organizational relationships, priority, and observability), whereas Theme 4 (staff buy-in) related to multiple subcomponents within the Motivation component but was ultimately viewed as a distinct construct. CONCLUSION: Our results highlight and explain how key readiness constructs impact the implementation of school-based physical activity opportunities. They also highlight the importance of obtaining staff buy-in when implementing in the school setting. This information is critical to developing readiness-building strategies that help schools improve their capacity to deliver physical activity opportunities effectively. TRIAL REGISTRATION: Not applicable.

Examining associations between school-level determinants and the implementation of physical activity opportunities.

School-based physical activity (PA) opportunities can help students engage in greater amounts of daily PA, meet PA guidelines, and lead to improved health and educational outcomes. However, we do not completely understand the organizational challenges to implementing these opportunities successfully. This exploratory study examined associations between school-level determinants and the implementation of school-based PA opportunities. We analyzed cross-sectional survey data from schools (n = 46) participating in the Healthy Zone School Program (HZSP) (Dallas, Texas, USA) during 2019-2020. Respondents completed an electronic survey that included measures of school-level determinants (e.g. culture, leadership, priority) and the implementation of school-based PA opportunities. We used linear regression models to examine associations between determinants and implementation outcomes (number of PA opportunities delivered, perceived overall success of each PA program/activity used). After adjusting for campus type (i.e. elementary, middle, high, K-12), student race/ethnicity, and percentage of economically disadvantaged students, no constructs were associated with the number of PA opportunities implemented. Linear regression models suggest access to knowledge and information (ß = 0.39, P = .012, 95% CI = 0.24-1.44) and implementation climate (ß = 0.34, P = .045, 95% CI = 0.02-1.59) were positively associated with the success of school-based PA opportunities. Our findings provide suggestive evidence that access to knowledge and information and a supportive school climate may improve the overall success of PA opportunities provided to students. Future research should examine additional school-level determinants to understand their importance to implementation and inform the development of strategies to improve schools' capacity for implementing PA opportunities successfully.

School-based physical activity (PA) opportunities (e.g. programs, activities, policies) help students engage in greater amounts of daily PA, meet national PA guidelines, and lead to improved health and educational outcomes. However, we do not completely understand the organizational challenges to implementing these opportunities successfully. This study explored what factors contribute to schools' ability to provide PA opportunities throughout the school year. We administered a survey to schools participating in the Healthy Zone Schools program during the 2019­20 academic year to assess the relationship between school-level determinants (e.g. culture, leadership, priority) and implementation outcomes related to school-based PA opportunities (e.g. number of programs and activities implemented, overall success of programs/activities implemented). We found no evidence of an association between determinants and the number of PA programs and activities implemented. However, we identified implementation climate and access to knowledge and information as key drivers of implementation success. This information can be used to develop implementation strategies that improve PA opportunities offered by schools.

Corrigendum: Application of implementation mapping to develop strategies for integrating the National Diabetes Prevention Program into primary care clinics.

[This corrects the article DOI: 10.3389/fpubh.2023.933253.].

Safety of the modified posteromedial approach in complex ankle fractures: Comparative analysis versus posterolateral access.

INTRODUCTION: The aim of the study was to evaluate the safety of the modified posteromedial approach (MfPM) in the surgical management of complex ankle fractures in terms of local complications. METHODS: Retrospective multicenter review of a series of malleolar fractures surgically treated by posterior ankle approaches between 2016 and 2022. Two approaches were used. In the MfPM group patients were placed in a prone position and the incision was made 1 cm medially to the Achilles tendon. In the posterolateral access (PL) group patients were placed in a prone or lateral decubitus position and the incision was made between the lateral malleolus and the Achilles tendon. Complications evaluated were divided into wound complications, infections, neuritis, vascular alterations and others. RESULTS: 81 ankle fractures with a posterior malleolar fragment treated by open reduction and internal fixation were identified. 20 cases were approached through the MfPM approach and 61 through the PL access. The mean follow up was 18.60 months (range 4-78 months). In the MfPM group the local complication rate was 10% (2/10 patients), both corresponding to minor wound problems which required no surgical intervention. No infection or other neural or vascular complications were found. In the PL group a complication rate of 8,19% (5/61 patients) was found, all of them corresponding to minor wound problems which required no surgical intervention. No infection or other neural or vascular complications were found. There were no significant differences between the two approaches regarding postoperative local complications (z score 0.249 - P: 0.803). CONCLUSION: The MfPM approach is safe and may become as readily used as the PL due to the low incidence of postoperative local complications, especially in fractures with a large fragment and posteromedial extension in which greater access to the posterior pilon can facilitate instrumentation for anatomic reduction and fixation.

Elementary school staff perspectives on the implementation of physical activity approaches in practice: an exploratory sequential mixed methods study.

Introduction: A whole-of-school approach is best to promote physical activity before, during, and after school. However, multicomponent programming is often complex and difficult to deliver in school settings. There is a need to better understand how components of a whole-of-school approach are implemented in practice. The objectives of this mixed methods study were to: (1) qualitatively explore physical activity approaches and their implementation in elementary schools, (2) quantitatively assess implementation levels, and (3) examine associations between school-level physical activity promotion and academic ratings. Methods: We used an exploratory sequential mixed methods design. We conducted semi-structured qualitative interviews with elementary school staff from a Texas school district and used a directed content analysis to explore physical activity approaches and their implementation. Using qualitative findings, we designed a survey to quantitatively examine the implementation of physical activity approaches, which we distributed to elementary staff district wide. We used Pearson correlation coefficients to examine the association between the amount of physical activity opportunities present in individual schools and school-level academic ratings. Results: We completed 15 interviews (7 principals/assistant principals, 4 physical educators, and 4 classroom teachers). Elementary school teachers and staff indicated PE and recess implementation was driven from the top-down by state and district policies, while implementation of classroom-based approaches, before and after school programming, and active transport were largely driven from the bottom-up by teachers and school leaders. Teachers and staff also discussed implementation challenges across approaches. Survey respondents (n = 247 from 22 schools) indicated 54.6% of schools were implementing ≥135 min/week of physical education and 72.7% were implementing 30 min/day of recess. Classroom-based approaches were less common. Twenty-four percent of schools reported accessible before school programs, 72.7% reported accessible after school programs, and 27% promoted active transport. There was a direct association between the number of physical activity opportunities provided and school-level academic ratings r(22) = 0.53, p = 0.01. Conclusion: Schools provided physical activity opportunities consistent with a whole-of-school approach, although there was variability between schools and implementation challenges were present. Leveraging existing school assets while providing school-specific implementation strategies may be most beneficial for supporting successful physical activity promotion in elementary schools.

A Qualitative Study of Knowledge of Metabolic Syndrome, Attitudes about Lifestyle Modifications, and Preferences for Lifestyle Interventions among Patients with Cancer and Metabolic Syndrome.

Background: Nearly 60% of patients with cancer have metabolic syndrome, which increases the risk of mortality, but there is no clear guidance for oncology providers about its management. Here, we report on the qualitative component of a larger mixed methods study that aimed to understand cancer patients' knowledge, attitudes, and preferences regarding metabolic syndrome. Methods: Adult cancer patients with metabolic syndrome were recruited during 2022-2023 in the MD Anderson General Internal Medicine clinic and participated in semistructured interviews focused on metabolic syndrome and lifestyle interventions. Interviews were audio-recorded and transcribed verbatim. Participants' demographic information was collected. Interviews were analyzed using hybrid thematic analysis and constant comparison involving deductive and inductive coding. Researcher triangulation and debriefing were used to ensure rigor. Results: There were 19 participants, 12 female and 12 White. Eighteen had solid tumors, including gynecologic (n = 5), genitourinary (n = 4), colorectal (n = 3), and breast (n = 2). Analysis yielded 5 major themes: 1) patients' understanding of metabolic syndrome; 2) attitudes about and approaches to managing metabolic syndrome; 3) capacity and limitations regarding managing metabolic syndrome; 4) patient-led care; and 5) tailored intervention plans. Participants had limited knowledge of metabolic syndrome and its cancer-related consequences; most desired additional education. Many participants reported that their cancer or diabetes diagnosis motivated them to prioritize lifestyle Modifications. Participants expressed strong interest in personalized care plans focused on healthy lifestyle rather than simply weight loss. As part of their tailored intervention plans, participants desired clear communication with their medical team, coordination of care among team members, and collaboration with providers about treatment decisions. Conclusion: Cancer patients with metabolic syndrome want collaborative, patient-centered care. Shared decision-making based on respect for patients' distinctive needs and preferences is an essential component of the development of such collaborative care. Tailored interventions, practical implementation strategies, and personalized care plans are needed for cancer patients with metabolic syndrome. The study findings contribute to filling the gap in knowledge regarding clear guidance for oncology providers on managing metabolic syndrome and will inform the development of future lifestyle interventions for patients diagnosed with metabolic syndrome.

Behavioral weight-loss interventions for patients with NAFLD: A systematic scoping review.

BACKGROUND: Clinically significant weight loss-which requires sustained dietary and physical activity changes-is central to treating NAFLD. Although behavioral interventions have demonstrated effectiveness in promoting weight loss among primary prevention populations, the data are limited among patients with NAFLD who need weight loss for treatment. We undertook this scoping review to map the existing data on the characteristics, weight-loss outcomes, and determinants of success of interventions evaluated among patients with NAFLD. METHODS: We searched Medline, EMBASE, Cochrane, PsycINFO, and Web of Science from inception to January 1, 2023 to identify publications reporting weight loss among adults with NAFLD in behavioral weight-loss interventions. We summarized interventions and classified them as successful if there was an average weight loss of ≥ 5% from baseline across enrolled participants or achieved by ≥ 50% of enrolled participants. RESULTS: We included 28 studies: 10 randomized control trials, ten quasi-experimental, and 8 observational studies. Intervention delivery, duration, and counseling frequency varied; 12 were successful. Retention was highest among telephone interventions and lowest among "real-world" face-to-face interventions. Patients who were women, younger, and/or had multiple metabolic conditions were most likely to dropout. Successful interventions had biweekly counseling, specific physical activity, and calorie targets, behavioral theory grounding, and promoted goal-setting, self-monitoring, and problem-solving. CONCLUSION: There are limited data on behavioral weight-loss interventions in NAFLD. Research is needed to develop effective interventions generalizable to diverse patient populations and that maximize adherence, particularly among patients who are diabetic, women, and younger.

Association of Diet Quality with Metabolic (Dysfunction) Associated Fatty Liver Disease in Veterans in Primary Care.

BACKGROUND: Diet is associated with metabolic (dysfunction)-associated fatty liver disease (MAFLD), but the dietary composition associated with MAFLD risk has not been well-examined. AIM: The purpose of this study was to assess the association of two healthy eating indices with the presence and severity of MAFLD in a sample of Veterans in a primary care setting. METHODS: This was a single center cross-sectional study using a random stratified sample of Veterans enrolled in primary care. Participants underwent a Fibroscan and completed an interviewer-administered Diet History Questionnaire II from which we calculated the Healthy Eating Index-2015 and Alternate Mediterranean Diet Score. We used multivariable logistic regression models to assess associations of dietary quality with MAFLD. RESULTS: We analyzed data from 187 participants, 53.5% of whom were female. On average, participants were 50.2 years of age (SD, 12.3 years) with an average BMI of 31.7 kg/m2. MAFLD was detected in 78 (42%) and at least moderate fibrosis in 12 (6%) participants. We found that the Alternate Mediterranean Diet Score was inversely associated with MAFLD (adjusted OR = 0.85, 95%CI 0.72-1.00), but controlling for BMI and total energy intake attenuated the association (adjusted OR = 0.92, 95%CI 0.74-1.15). We found no statistically significant associations between the Healthy Eating Index-2015 and MAFLD or advanced fibrosis. DISCUSSION: We found that the Alternate Mediterranean Diet Score was significantly associated with lower MAFLD risk in Veterans; however, the association was mediated by BMI and total energy intake. A Mediterranean-style diet could potentially help reduce the risk of MAFLD, particularly if it helps control total energy intake and weight.

Physician Views on the Provision of Information on Immune Checkpoint Inhibitor Therapy to Patients with Cancer and Pre-Existing Autoimmune Disease: A Qualitative Study.

Immune checkpoint inhibitors (ICIs) have improved cancer outcomes but can cause severe immune-related adverse events (irAEs) and flares of autoimmune conditions in cancer patients with pre-existing autoimmune disease. The objective of this study was to identify the information physicians perceived as most useful for these patients when discussing treatment initiation with ICIs. Twenty physicians at a cancer institution with experience in the treatment of irAEs were interviewed. Qualitative thematic analysis was performed to organize and interpret data. The physicians were 11 medical oncologists and 9 non-oncology specialists. The following themes were identified: (1) current methods used by physicians to provide information to patients and delivery options; (2) factors to make decisions about whether or not to start ICIs in patients who have cancer and pre-existing autoimmune conditions; (3) learning points for patients to understand; (4) preferences for the delivery of ICI information; and (5) barriers to the implementation of ICI information in clinics. Regarding points to discuss with patients, physicians agreed that the benefits of ICIs, the probability of irAEs, and risks of underlying autoimmune condition flares with the use of ICIs were most important. Non-oncologists were additionally concerned about how ICIs affect the autoimmune disease (e.g., impact on disease activity, need for changes in medications for the autoimmune disease, and monitoring of autoimmune conditions).

Linking social and built environmental factors to leisure-time physical activity in rural cancer survivors.

BACKGROUND: This study explored associations between social and built environmental factors and leisure-time physical activity (LTPA) in rural cancer survivors (RCS) and whether these associations differed by exercise stage of change (SOC). METHOD: RCS (n = 219) completed questionnaires assessing LTPA, SOC, and social (social status, connectedness, support) and environmental (home environment, neighborhood environment) factors. Linear regression models examined associations between social and built environmental factors and LTPA and tested for moderation by SOC. RESULTS: Half (50.7%) of RCS were physically active, and 49.3% were not active. Social factors positively associated with LTPA included subjective social status in the community (B = 89.0, P = .014) and in the United States (B = 181.3, P < .001), social connectedness (B = 122.3, P = .024), and social support for physical activity from family (B = 41.9, P < .001) and friends (B = 44.3, P < .001). Environmental factors positively associated with LTPA included the home environment (B = 111.2, P < .001), perceived environmental support for PA (B = 355.4, P = .004), and neighborhood attributes, including bicycling infrastructure (B = 191.3, P = .003), proximity to recreation facilities (B = 140.1, P = .021), traffic safety (B = 184.5, P = .025), and aesthetics (B = 342.6, P < .001). SOC statistically significantly moderated the association between social status in the United States and LTPA (B = 160.3, P = .031). CONCLUSIONS: Social and built environmental factors were consistently linked with LTPA and provide context for multilevel interventions promoting LTPA in RCS.

Application of implementation mapping to develop strategies for integrating the National Diabetes Prevention Program into primary care clinics.

Background: Diabetes is considered one of the most prevalent and preventable chronic health conditions in the United States. Research has shown that evidence-based prevention measures and lifestyle changes can help lower the risk of developing diabetes. The National Diabetes Prevention Program (National DPP) is an evidence-based program recognized by the Centers for Disease Control and Prevention; it is designed to reduce diabetes risk through intensive group counseling in nutrition, physical activity, and behavioral management. Factors known to influence this program's implementation, especially in primary care settings, have included limited awareness of the program, lack of standard clinical processes to facilitate referrals, and limited reimbursement incentives to support program delivery. A framework or approach that can address these and other barriers of practice is needed. Objective: We used Implementation Mapping, a systematic planning framework, to plan for the adoption, implementation, and maintenance of the National DPP in primary care clinics in the Greater Houston area. We followed the framework's five iterative tasks to develop strategies that helped to increase awareness and adoption of the National DPP and facilitate program implementation. Methods: We conducted a needs assessment survey and interviews with participating clinics. We identified clinic personnel who were responsible for program use, including adopters, implementers, maintainers, and potential facilitators and barriers to program implementation. The performance objectives, or sub-behaviors necessary to achieve each clinic's goals, were identified for each stage of implementation. We used classic behavioral science theory and dissemination and implementation models and frameworks to identify the determinants of program adoption, implementation, and maintenance. Evidence- and theory-based methods were selected and operationalized into tailored strategies that were executed in the four participating clinic sites. Implementation outcomes are being measured by several different approaches. Electronic Health Records (EHR) will measure referral rates to the National DPP. Surveys will be used to assess the level of the clinic providers and staff's acceptability, appropriateness of use, feasibility, and usefulness of the National DPP, and aggregate biometric data will measure the level of the clinic's disease management of prediabetes and diabetes. Results: Participating clinics included a Federally Qualified Health Center, a rural health center, and two private practices. Most personnel, including the leadership at the four clinic sites, were not aware of the National DPP. Steps for planning implementation strategies included the development of performance objectives (implementation actions) and identifying psychosocial and contextual implementation determinants. Implementation strategies included provider-to-provider education, electronic health record optimization, and the development of implementation protocols and materials (e.g., clinic project plan, policies). Conclusion: The National DPP has been shown to help prevent or delay the development of diabetes among at-risk patients. Yet, there remain many challenges to program implementation. The Implementation Mapping framework helped to systematically identify implementation barriers and facilitators and to design strategies to address them. To further advance diabetes prevention, future program, and research efforts should examine and promote other strategies such as increased reimbursement or use of incentives and a better billing infrastructure to assist in the scale and spread of the National DPP across the U.S.

Association of lifestyle behaviors with non-alcoholic fatty liver disease and advanced fibrosis detected by transient elastography among Hispanic/Latinos adults in the U.S.

OBJECTIVES: Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent liver disease, with the highest prevalence observed in the U.S. among Hispanic/Latino adults. While physical activity and dietary behaviors have established protective associations with NAFLD and its severity, these associations have not been well-characterized in Hispanic/Latino adults. The purpose of this study was to assess the association of lifestyle behaviors with NAFLD and advanced fibrosis in US Hispanic/Latino adults. DESIGN: We selected all Hispanic/Latino adults from the 2017-2018 National Health and Nutrition Examination Survey (NHANES). NAFLD was defined as CAP ≥285 dB/m, and advanced fibrosis as liver stiffness measurements ≥8.6 kPa. Multivariate-adjusted logistic regression models assessed associations of physical activity and sedentary behavior (Global Physical Activity Questionnaire), as well as diet quality (Healthy Eating Index [HEI]-2015) and total energy intake (24-hour recall) with NAFLD and advanced fibrosis. RESULTS: In Hispanic/Latino adults, the overall prevalence of NAFLD was 41.5%, while the prevalence of advanced fibrosis among those with NAFLD was 17.2%. We found that higher levels of physical activity and high diet quality were associated with lower risk of NAFLD. Compared to those reporting on average 0 metabolic equivalent (MET) hours/week of physical activity, participants reporting high levels of physical activity (≥32 MET hours/week) had 40% lower risk of NAFLD (Adjusted OR = 0.60, 95%CI 0.38, 0.93). High diet quality (HEI-2015) was associated with a 30% lower risk of NAFLD (Adjusted OR = 0.70, 95% CI 0.51, 0.97) and 72% lower risk of advanced fibrosis (Adjusted OR = 0.28, 95% CI 0.12, 0.66), as compared to those with low diet quality. CONCLUSIONS: In this population-based study, high levels of physical activity and diet quality were associated with lower risk of NAFLD in Hispanic/Latino adults. Public health and medical professionals need to concentrate efforts on lifestyle behavior change in Hispanic/Latino adults who are at high risk for serious liver disease.

Using implementation mapping for the adoption and implementation of Target:BP in community health centers.

Background: Despite the availability of multilevel evidence-based interventions for blood pressure management, poor hypertension control is common among community health center patient populations across the state of Texas and the United States. Target:BP TM is a national initiative from the American Heart Association and the American Medical Association to assist healthcare organizations and care teams in improving blood pressure control rates using evidence-based approaches and recognition of organizations who have successfully integrated the program in their practice. Using the Implementation Mapping approach, we identified determinants of Target:BP TM adoption and use and developed implementation strategies to improve program uptake and implementation in Community Health Centers in Texas. Methods: We used Implementation Mapping (IM) to identify barriers and facilitators influencing the adoption and implementation of the Target:BP TM program and develop strategies to increase program adoption and use. We recruited four clinics across four counties in Texas and assessed barriers and facilitators at the organizational level, including electronic health records and data use. We used this data to inform clinic-specific implementation strategies based on the organization capacity and priorities feedback. We developed an implementation plan and timeline designed to improve the implementation and maintenance of Target:BP TM . Results: As part of the needs and capacity assessment, we collected data through interviews with CHC staff, examining gaps in needs and services (e.g., what do clinics need to implement Target:BP TM ?), and assets to leverage. We worked with Community Health Centers to a) identify individuals who would be involved in the adoption, implementation, and maintenance of Target:BP TM , b) describe adoption and implementation actions, and c) identify barriers and facilitators influencing adoption and implementation. Together with partners from Community Health Center, we used the IM approach to identify and develop program goals, identify methods and strategies to address barriers, and create an implementation plan. Our strategies included monthly or biweekly meetings to provide technical support, reviewing program goals and timeline to ensure program implementation, progress toward reaching goals, and address quality improvement needs at each clinic site. We developed a Target:BP TM implementation protocol for each clinic based on the needs and capacity assessment, identification of technology use and capacity, and gap analysis. We reviewed Target:BP TM program strategies and self-measured blood pressure protocols tailored to the clinic patient population. We developed a collaborative plan, reviewed funding and capacity for implementation, and provided continuous quality improvement guidance. Ongoing process and impact evaluations using the Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) framework are underway. Discussion: This paper provides an example of using Implementation Mapping to develop strategies to increase the adoption and implementation of evidence-based cardiovascular risk reduction interventions in Community Health Centers. The use of implementation strategies can increase the use of Target:BP TM in Community Health Centers and improve hypertension control.