Action Planning for Building Program Sustainability: Results from a Group-Randomized Trial.

Background: Public health programs are charged with implementing evidence-based interventions to support public health improvement, however, to achieve long term population based benefit these interventions must be sustained. Empirical evidence suggests that program sustainability can be improved through training and technical assistance, but few resources are available to support public health programs in building capacity for sustainability. Methods: This study sought to build capacity for sustainability among state tobacco control programs through a multiyear, group-randomized trial that developed, tested, and evaluated a novel Program Sustainability Action Planning Model and Training Curricula. Using Kolb's experiential learning theory, we developed this action-oriented training model to address the program-related domains proven to impact capacity for sustainability as outlined in the Program Sustainability Framework. We evaluated the intervention using a longitudinal mixed-effects model using Program Sustainability Assessment (PSAT) scores from three time points. The main predictors in our model included group (control vs intervention) and type of dosage (active and passive). Covariates included state level American Lung Association score (proxy for tobacco control policy environment) and percent of CDC-recommended funding (proxy for program resources). Results: Twenty-three of the 24 state tobacco control programs were included in the analyses: 11 received the training intervention and 12 were control. Results of the longitudinal mixed-effects linear regression model, where the annual PSAT score was the outcome, showed that states in the intervention condition reported significantly higher PSAT scores. The effects for CDC-recommended funding and American Lung Association smoke-free scores (proxy for policy environment) were small but statistically significant. Conclusion: This study found that the Program Sustainability Action Planning Model and Training Curricula was effective in building capacity for sustainability. The training was most beneficial for programs that had made less policy progress than others, implying that tailored training may be most appropriate for programs possibly struggling to make progress. Finally, while funding had a small, statistically significant effect in our model, it virtually made no difference for the average program in our study. This suggests that other factors may be more or equally important as the level of funding a program receives. Trial registration: NCT03598114, Registered on July 26, 2018 (clnicaltrials.gov/NCT03598114).

Understanding Misimplementation in U.S. State Health Departments: An Agent-Based Model.

INTRODUCTION: The research goal of this study is to explore why misimplementation occurs in public health agencies and how it can be reduced. Misimplementation is ending effective activities prematurely or continuing ineffective ones, which contributes to wasted resources and suboptimal health outcomes. METHODS: The study team created an agent-based model that represents how information flow, filtered through organizational structure, capacity, culture, and leadership priorities, shapes continuation decisions. This agent-based model used survey data and interviews with state health department personnel across the U.S. between 2014 and 2020; model design and analyses were conducted with substantial input from stakeholders between 2019 and 2021. The model was used experimentally to identify potential approaches for reducing misimplementation. RESULTS: Simulations showed that increasing either organizational evidence-based decision-making capacity or information sharing could reduce misimplementation. Shifting leadership priorities to emphasize effectiveness resulted in the largest reduction, whereas organizational restructuring did not reduce misimplementation. CONCLUSIONS: The model identifies for the first time a specific set of factors and dynamic pathways most likely driving misimplementation and suggests a number of actionable strategies for reducing it. Priorities for training the public health workforce include evidence-based decision making and effective communication. Organizations will also benefit from an intentional shift in leadership decision-making processes. On the basis of this initial, successful application of agent-based model to misimplementation, this work provides a framework for further analyses.

The power of partnerships: state public health department multisector collaborations in major chronic disease programme areas in the United States.

BACKGROUND: Multisector collaboration between state public health departments (SHDs) and diverse community partners is increasingly recognized as important for promoting positive public health outcomes, addressing social determinants of health, and reducing health inequalities. This study investigates collaborations between SHDs in the United States and different types of organizations addressing chronic disease in and outside of the health sector. METHODS: SHD employees were randomly selected from the National Association of Chronic Disease Directors membership list for participation in an online survey. Participants were asked about their primary chronic disease work unit (cancer, obesity, tobacco, diabetes, cardiovascular disease, and others), as well as their work unit collaborations (exchange of information/cooperation in activities) with organizations in health and non-health sectors. As a measure of the different organizations SHDs collaborated with in health and non-health sectors, a collaboration heterogeneity score for each programme area was calculated. One-way analysis of variance (ANOVA) with Tukey's post hoc tests were used to assess differences in collaborator heterogeneity between programme areas. RESULTS: A total of 574 participants were surveyed. Results indicated that the cancer programme area, along with diabetes and cardiovascular disease, had significantly less collaboration heterogeneity with organizations outside of the health sector compared to the obesity and tobacco programme areas. CONCLUSIONS: While collaborations with health sector organizations are commonly reported, public health departments can increase collaboration with sectors outside of health to more fully address chronic disease prevention.

"It's good to feel like you're doing something": a qualitative study examining state health department employees' views on why ineffective programs continue to be implemented in the USA.

BACKGROUND: Mis-implementation, the inappropriate continuation of programs or policies that are not evidence-based or the inappropriate termination of evidence-based programs and policies, can lead to the inefficient use of scarce resources in public health agencies and decrease the ability of these agencies to deliver effective programs and improve population health. Little is known about why mis-implementation occurs, which is needed to understand how to address it. This study sought to understand the state health department practitioners' perspectives about what makes programs ineffective and the reasons why ineffective programs continue. METHODS: Eight state health departments (SHDs) were selected to participate in telephone-administered qualitative interviews about decision-making around ending or continuing programs. States were selected based on geographic representation and on their level of mis-implementation (low and high) categorized from our previous national survey. Forty-four SHD chronic disease staff participated in interviews, which were audio-recorded and transcribed verbatim. Transcripts were consensus coded, and themes were identified and summarized. This paper presents two sets of themes, related to (1) what makes a program ineffective and (2) why ineffective programs continue to be implemented according to SHD staff. RESULTS: Participants considered programs ineffective if they were not evidence-based or if they did not fit well within the population; could not be implemented well due to program restraints or a lack of staff time and resources; did not reach those who could most benefit from the program; or did not show the expected program outcomes through evaluation. Practitioners described several reasons why ineffective programs continued to be implemented, including concerns about damaging the relationships with partner organizations, the presence of program champions, agency capacity, and funding restrictions. CONCLUSIONS: The continued implementation of ineffective programs occurs due to a number of interrelated organizational, relational, human resources, and economic factors. Efforts should focus on preventing mis-implementation since it limits public health agencies' ability to conduct evidence-based public health, implement evidence-based programs effectively, and reduce the high burden of chronic diseases. The use of evidence-based decision-making in public health agencies and supporting adaptation of programs to improve their fit may prevent mis-implementation. Future work should identify effective strategies to reduce mis-implementation, which can optimize public health practice and improve population health.

FTO rs9939609 A allele influences anthropometric outcome in response to dietary intervention, but not in response to physical exercise program.

PURPOSE: The fat mass and obesity-associated (FTO) gene is involved in energy homeostasis. The A allele of the rs9939609 (SNP; T>A) is associated with obesity and higher food intake, while its effect in energy expenditure remains unclear. The aim of this study is to examine whether FTO rs9939609 is associated with the anthropometric outcomes of a physical exercise program and a dietary intervention. METHODS: We studied two independent samples. The first was composed by children and adolescents in which overweight and obese individuals were submitted to a physical exercise program (n = 136) and normal weight participants served as a control group (n = 172). The second sample was composed by obese women submitted to a hypocaloric dietary intervention (n = 126). RESULTS: Physical exercise and dietary intervention were effective, independently of genotype. We found no association of FTO rs9939609 with obesity in children and adolescents (p = 0.67). The rs9939609 affected the response to dietary intervention in obese women: A allele carriers reduced 2.7 cm less of abdominal circumference (AC) than homozygous TT (p = 0.04), while no effect was observed in response to physical exercise in overweight and obese children and adolescents. CONCLUSIONS: The A allele is associated with a worse outcome in response to the hypocaloric dietary intervention regarding abdominal circumference reduction; the same allele did not show interaction with any anthropometric outcomes in response to the exercise program applied.

Effects of energetic restriction diet on butyrylcholinesterase in obese women from southern Brazil - A longitudinal study

Objective Butyrylcholinesterase (BChE) activity has been associated with obesity, lipid concentrations, and CHE2 locus phenotypes. This, the aim of this study was to evaluate the effects of an energetic restriction diet intervention on anthropometrical and biochemical variables and on absolute and relative BChE activity in CHE2 C5+ and CHE2 C5- individuals. Subjects and methods One hundred eleven premenopausal obese women from Southern Brazil participated in an energetic restriction diet intervention (deficit of 2500 kJ/day) for 8 weeks. Their anthropometric and biochemical parameters were evaluated before and after the intervention. Plasma BChE activity was measured, and BChE bands in plasma and CHE2 locus phenotypes were detected by electrophoresis. Results The dietetic intervention decreased anthropometric and biochemical parameters as well as absolute BChE activity and relative activity of the G4 band. The CHE2 C5+ phenotype presented a different effect when compared with the CHE2 C5- phenotype. The CHE2 C5+ phenotype showed an effect in absolute BChE activity and in the relative activity of the G4 form, maintaining higher BChE activity regardless of the metabolic changes. Conclusion In our study, 8 weeks was not sufficient time to lower the body mass index to normal, but it was enough to significantly reduce the absolute BChE activity, which became similar to the levels in nonobese individuals. CHE2 C5+ individuals were resistant to the decrease in BChE activity compared to CHE2 C5- individuals. This shows that the diet did not affect the CHE2 and G4 fraction complex and that the products of the CHE2 locus in association with BChE have a role in energy metabolism, maintaining high levels of enzymatic activity even after dietary intervention.

Effects of energetic restriction diet on butyrylcholinesterase in obese women from southern Brazil - A longitudinal study.

OBJECTIVE: Butyrylcholinesterase (BChE) activity has been associated with obesity, lipid concentrations, and CHE2 locus phenotypes. This, the aim of this study was to evaluate the effects of an energetic restriction diet intervention on anthropometrical and biochemical variables and on absolute and relative BChE activity in CHE2 C5+ and CHE2 C5- individuals. SUBJECTS AND METHODS: One hundred eleven premenopausal obese women from Southern Brazil participated in an energetic restriction diet intervention (deficit of 2500 kJ/day) for 8 weeks. Their anthropometric and biochemical parameters were evaluated before and after the intervention. Plasma BChE activity was measured, and BChE bands in plasma and CHE2 locus phenotypes were detected by electrophoresis. RESULTS: The dietetic intervention decreased anthropometric and biochemical parameters as well as absolute BChE activity and relative activity of the G4 band. The CHE2 C5+ phenotype presented a different effect when compared with the CHE2 C5- phenotype. The CHE2 C5+ phenotype showed an effect in absolute BChE activity and in the relative activity of the G4 form, maintaining higher BChE activity regardless of the metabolic changes. CONCLUSION: In our study, 8 weeks was not sufficient time to lower the body mass index to normal, but it was enough to significantly reduce the absolute BChE activity, which became similar to the levels in nonobese individuals. CHE2 C5+ individuals were resistant to the decrease in BChE activity compared to CHE2 C5- individuals. This shows that the diet did not affect the CHE2 and G4 fraction complex and that the products of the CHE2 locus in association with BChE have a role in energy metabolism, maintaining high levels of enzymatic activity even after dietary intervention.

Effect of BCHE single nucleotide polymorphisms on lipid metabolism markers in women

Abstract Butyrylcholinesterase (BChE) activity and polymorphisms in its encoding gene had previously been associated with metabolic traits of obesity. This study investigated the association of three single nucleotide polymorphisms (SNPs) in the BCHE gene: -116G > A (rs1126680), 1615GA (rs1803274), 1914A < G (rs3495), with obesity and lipid metabolism markers, body mass index (BMI), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), triglyceride (TG) levels, and BChE enzymatic activity in obese (BMI≥30/n = 226) and non-obese women (BMI < 25/n = 81). BCHE SNPs genotyping was obtained by TaqMan allelic discrimination assay and by RFLP-PCR. Plasmatic BChE activity was measured using propionylthiocholine as substrate. Similar allele frequencies were found in obese and non-obese women for the three studied SNPs (p > 0.05). The dominant and recessive models were tested, and different effects were found. The -116A allele showed a dominant effect in BChE activity reduction in both non-obese and obese women (p = 0.045 and p < 0.001, respectively). The 1914A > G and 1615GA SNPs influenced the TG levels only in obese women. The 1914G and the 1615A alleles were associated with decreased plasma levels of TG. Thus, our results suggest that the obesity condition, characterized by loss of energy homeostasis, is modulated by BCHE polymorphisms.

Effect of BCHE single nucleotide polymorphisms on lipid metabolism markers in women.

Butyrylcholinesterase (BChE) activity and polymorphisms in its encoding gene had previously been associated with metabolic traits of obesity. This study investigated the association of three single nucleotide polymorphisms (SNPs) in the BCHE gene: -116G > A (rs1126680), 1615GA (rs1803274), 1914A < G (rs3495), with obesity and lipid metabolism markers, body mass index (BMI), total cholesterol (TC), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C), triglyceride (TG) levels, and BChE enzymatic activity in obese (BMI≥30/n = 226) and non-obese women (BMI < 25/n = 81). BCHE SNPs genotyping was obtained by TaqMan allelic discrimination assay and by RFLP-PCR. Plasmatic BChE activity was measured using propionylthiocholine as substrate. Similar allele frequencies were found in obese and non-obese women for the three studied SNPs (p > 0.05). The dominant and recessive models were tested, and different effects were found. The -116A allele showed a dominant effect in BChE activity reduction in both non-obese and obese women (p = 0.045 and p < 0.001, respectively). The 1914A > G and 1615GA SNPs influenced the TG levels only in obese women. The 1914G and the 1615A alleles were associated with decreased plasma levels of TG. Thus, our results suggest that the obesity condition, characterized by loss of energy homeostasis, is modulated by BCHE polymorphisms.

Zinco no plasma e eritrócito de atletas profissionais de uma equipe feminina brasileira de voleibol / Plasma and erythrocyte zinc in Brazilian professional female volleyball players

OBJETIVO: Avaliar o estado nutricional relativo ao zinco de 12 atletas profissionais do voleibol feminino. MÉTODOS: Determinou-se a concentração de zinco plasmático e eritrocitário por espectrofotometria de absorção atômica, e avaliou-se a ingestão dietética por meio de registro alimentar de três dias, de 12 atletas profissionais do sexo feminino, integrantes de uma equipe de voleibol de Curitiba, PR, na faixa etária de 18 a 24 anos, no ano de 2003. RESULTADOS: Todas as atletas apresentaram valores normais de zinco plasmático. Quanto ao zinco eritrocitário, 100,00 por cento apresentaram valores abaixo da normalidade. Em relação à ingestão dietética de zinco, 83,33 por cento apresentaram adequação. Decréscimos no conteúdo de zinco eritrocitário podem representar o efeito agudo de exercícios prolongados pela utilização enzimática da superóxido dismutase ou anidrase carbônica. CONCLUSÃO: O estado nutricional das atletas relativo ao zinco parece estar inadequado, pois, apesar dos valores normais para a concentração de zinco plasmático, a concentração eritrocitária esteve abaixo da faixa de normalidade para todas as atletas.

OBJECTIVE: This study aimed to evaluate the nutritional status of zinc in 12 female volleyball players. METHODS: Zinc levels in plasma and erythrocytes were assessed by atomic absorption spectrophotometry. Zinc intake of 12 professional female athletes of a volleyball team from Curitiba, PR, aging from 18 to 24 years in 2003, was determined by a 3-day food record. RESULTS: All athletes presented normal plasma zinc values. Erythrocyte zinc was lower than normal in 100 percent of the athletes. Dietary intake of zinc was adequate in 83.33 percent. The significant decreases in erythrocyte content could represent the acute effects of prolonged exercises which increases superoxide dismutase or carbonic anhydrase utilization. CONCLUSION: The athletes' zinc nutritional status seemed to be inadequate. They had normal plasma zinc levels but the erythrocyte zinc was below the normal values for all of them.