Addressing Health Inequities: An Exploratory Assessment of Extension Educators' Perceptions of Program Demand for Diverse Communities.

Land grant universities are a key provider of community-based health promotion programs through the Cooperative Extension Service. However, Extension's current approach to addressing systemic social determinants of health is incomplete and inconsistent. The purpose of this study was to explore Extension health educators' perceptions of demand for health promotion programming targeting audiences most likely to experience health inequities. Health educators within 2 state Extension systems were invited to complete an online survey based on a capacity building model. Survey questions included rating perceptions of demand for programming for health disparate populations: low-income; Black and African American; Hispanic, Latino/a, Latinx; persons with disabilities; immigrants and refugees; and lesbian, gay, bisexual, and transgender. Analysis of variance and Bonferroni post hoc testing was used to determine differences in perceived demand between populations. Ninety-six educators completed the survey. Perceived demand for low-income population programming was significantly higher than for other populations. Perceived programming demand for immigrants and refugees and lesbian, gay, bisexual, and transgender people was significantly lower than for other populations. Individual and organizational-level factors, including racism and Extension's historical scope, likely contribute to the results. Engaging historically excluded Extension audiences requires time and resources to improve the Extension system and educator capacity for relationship building, trust building, and communication.

Assess, Plan, Do, Evaluate, and Report: Iterative Cycle to Remove Academic Control of a Community-Based Physical Activity Program.

PURPOSE AND OBJECTIVES: Responsive methods and measures are needed to bridge research to practice and address public health issues, such as older adults' need for multicomponent physical activity. The objective of this study was to detail the longitudinal, quasi-experimental work that spans 5 years to describe outcomes across RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) dimensions of integrating a physical activity intervention for older adults into the Cooperative Extension System through the assess, plan, do, evaluate, report (APDER) cycle. INTERVENTION APPROACH: The participant-level intervention is Lifelong Improvements through Fitness Together (LIFT), an 8-week, group dynamics-based, strength-training program with 16 in-person sessions. The implementation intervention applies the iterative APDER cycle based on feedback for each dimension of RE-AIM. Each year, the APDER cycle was used to embed data collection procedures at the instructor and participant level to reveal the next evolution of the program. EVALUATION METHODS: Each evolution of LIFT was measured through a pretest and posttest quasi-experimental design. Data were collected on each RE-AIM dimension through participant surveys and functional fitness assessments, number and representativeness of trainees, and process evaluation. RESULTS: Overall, LIFT was expanded to 4 states with 275 instructors, reaching 816 older adults; consistently improved functional fitness outcome measures; demonstrated strong program adherence; and was seen as feasible and enjoyable by instructors and participants. LIFT is now undergoing adaptations for virtual delivery as well as updating the exercise protocol to introduce yoga postures that target flexibility and balance. IMPLICATIONS FOR PUBLIC HEALTH: Overall, ongoing adaptations were necessary to ensure the program continued to fit the mission, values, and resources of the delivery system. Public health implications to support the need for ongoing adaptation include embedding pragmatic measures of adaptations and RE-AIM into standard evaluation pathways and using iterative APDER cycles.

Using pre- and post-survey instruments in interventions: determining the random response benchmark and its implications for measuring effectiveness.

OBJECTIVE: The present communication demonstrates that even if individuals are answering a pre/post survey at random, the percentage of individuals showing improvement from the pre- to the post-survey can be surprisingly high. Some simple formulas and tables are presented that will allow analysts to quickly determine the expected percentage of individuals showing improvement if participants just answered the survey at random. This benchmark percentage, in turn, defines the appropriate null hypothesis for testing if the actual percentage observed is greater than the expected random answering percentage. DESIGN: The analysis is demonstrated by testing if actual improvement in a component of the US Department of Agriculture's (USDA) Expanded Food and Nutrition Education Program is significantly different from random answering improvement. SETTING: USA. SUBJECTS: From 2011 to 2014, 364320 adults completed a standardized pre- and post-survey administered by the USDA. RESULTS: For each year, the statement that the actual number of improvements is less than the expected number if the questions were just answered at random cannot be rejected. This does not mean that the pre-/post-test survey instrument is flawed, only that the data are being inappropriately evaluated. CONCLUSIONS: Knowing the percentage of individuals showing improvement on a pre/post survey instrument when questions are randomly answered is an important benchmark number to determine in order to draw valid inferences about nutrition interventions. The results presented here should help analysts in determining this benchmark number for some common survey structures and avoid drawing faulty inferences about the effectiveness of an intervention.

Why do Older Adults Decline Participation in Research? Results from Two Deprescribing Clinical Trials.

Background Heterogenous older adult populations are underrepresented in clinical trials, and their participation is necessary for interventions that directly target them. The purpose of this study was to evaluate reasons why hospitalized older adults declined participation in two deprescribing clinical trials. Methods We report enrollment data from two deprescribing trials, Shed-MEDS (non-Veterans) and VA DROP (Veterans). For both trials, inclusion criteria required participants to be hospitalized, age 50 or older, English-speaking, and taking five or more home medications. Eligible patients were approached for enrollment while hospitalized. When an eligible patient or surrogate declined participation, the reason(s) were recorded and subsequently analyzed inductively to develop themes, and a Chi-square test was used for comparison. Results Across both trials, 1226 patients (545 non-Veterans and 681 Veterans) declined enrollment and provided reasons, which were condensed into three themes: (1) feeling overwhelmed by their current health status, (2) lack of interest or mistrust of research, and (3) hesitancy to participate in a deprescribing study. A greater proportion of Veterans expressed a lack of interest or mistrust in research (42% vs 26%, chi-square value = 36.72, p < .001); whereas a greater proportion of non-Veterans expressed feeling overwhelmed by their current health status (54% vs 35%, chi-square value = 42.8 p < 0.001). Across both trials, similar proportion of patients expressed hesitancy to participate in a deprescribing study, with no significant difference between Veterans and non-Veterans (23% and 21%). Conclusions The inclusion of older adults in clinical trial research broadens its impact. Understanding the reasons older adults decline participation can inform future strategies to engage this multimorbid population.

Why do older adults decline participation in research? Results from two deprescribing clinical trials.

BACKGROUND: Heterogenous older adult populations are underrepresented in clinical trials, and their participation is necessary for interventions that directly target them. The purpose of this study was to evaluate reasons why hospitalized older adults declined participation in two deprescribing clinical trials. METHODS: We report enrollment data from two deprescribing trials, Shed-MEDS (non-Veterans) and VA DROP (Veterans). For both trials, inclusion criteria required participants to be hospitalized, age 50 or older, English-speaking, and taking five or more home medications. Eligible patients were approached for enrollment while hospitalized. When an eligible patient or surrogate declined participation, the reason(s) were recorded and subsequently analyzed inductively to develop themes, and a chi-square test was used for comparison (of themes between Veterans and non-Veterans). RESULTS: Across both trials, 1226 patients (545 non-Veterans and 681 Veterans) declined enrollment and provided reasons, which were condensed into three themes: (1) feeling overwhelmed by their current health status, (2) lack of interest or mistrust of research, and (3) hesitancy to participate in a deprescribing study. A greater proportion of Veterans expressed a lack of interest or mistrust in research (42% vs 26%, chi-square value = 36.72, p < .001), whereas a greater proportion of non-Veterans expressed feeling overwhelmed by their current health status (54% vs 35%, chi-square value = 42.8 p < 0.001). Across both trials, similar proportion of patients expressed hesitancy to participate in a deprescribing study, with no significant difference between Veterans and non-Veterans (23% and 21%). CONCLUSIONS: Understanding the reasons older adults decline participation can inform future strategies to engage this multimorbid population.

Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study adaptations in lung cancer screening delivery in the Veterans Health Administration: a cohort study.

BACKGROUND: Lung cancer screening is a complex clinical process that includes identification of eligible individuals, shared decision-making, tobacco cessation, and management of screening results. Adaptations to the delivery process for lung cancer screening in situ are understudied and underreported, with the potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for a systematic enumeration of adaptations to implementation of evidence-based practices. We applied FRAME to study adaptations in lung cancer screening delivery processes implemented by lung cancer screening programs in a Veterans Health Administration (VHA) Enterprise-Wide Initiative. METHODS: We prospectively conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMCs) between 2019 and 2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, documented, and mapped to FRAME categories. RESULTS: We conducted a total of 16 interviews across 10 VHA lung cancer screening programs (n=6 in year 1, n=10 in year 2) to collect adaptations. In year 1 (2020), six programs were operational and eligible. Of these, three reported adaptations to their screening process that were planned or in response to COVID-19. In year 2 (2021), all 10 programs were operational and eligible. Programs reported 14 adaptations in year 2. These adaptations were planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to the identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 60% of programs to improve the data collection and tracking of Veterans in the screening process. CONCLUSIONS: Using FRAME, we found that adaptations occurred primarily in the areas of patient identification and communication of results due to increased workload. These findings highlight navigator time and resource considerations for sustainability and scalability of existing and future lung cancer screening programs as well as potential areas for future intervention.

Dissemination in Extension: Health Specialists' Information Sources and Channels for Health Promotion Programming.

In the National Cooperative Extension System (herein: Extension), state-level specialists serve as key intermediaries between research, educators, and the community members they serve. There is a need to understand information seeking and sharing practices (i.e., dissemination) among specialists to increase the adoption of evidence-based health promotion programs. Specialists (N = 94) across 47 states were identified and invited to participate in this mixed methods study. A one-way ANOVA with Bonferroni corrections was used to analyze survey data. Data collected through semi-structured interviews were analyzed using an immersion crystallization approach. Forty-seven health specialists completed the survey representing 31 eligible states (65%) and were predominately female (89%), Caucasian (70%), had a doctorate (62%), and were employed within Extension for 10.2 + 9.7 years. The information sources used most frequently were academic journals and other specialists, and most used email and online meetings to communicate. Qualitative findings support the use of other specialists as a primary source of information and indicate specialists' desire for an on-demand, bi-directional, online national repository of Extension programs. This repository would facilitate the dissemination of evidence-based programming across the system and reduce program duplication as well as information burden on county-based educators.

Using the Framework for Reporting Adaptations and Modifications-Expanded (FRAME) to study lung cancer screening adaptations in the Veterans Health Administration.

Background: Lung cancer screening includes identification of eligible individuals, shared decision-making inclusive of tobacco cessation, and management of screening results. Adaptations to the implemented processes for lung cancer screening in situ are understudied and underreported, with potential loss of important considerations for improved implementation. The Framework for Reporting Adaptations and Modifications-Expanded (FRAME) allows for systematic enumeration of adaptations to implementations of evidence-based practices. We used FRAME to study adaptations in lung cancer screening processes that were implemented as part of a Veterans Health Administration (VHA) Enterprise-Wide Initiative. Methods: We conducted semi-structured interviews at baseline and 1-year intervals with lung cancer screening program navigators at 10 Veterans Affairs Medical Centers (VAMC) between 2019-2021. Using this data, we developed baseline (1st) process maps for each program. In subsequent years (year 1 and year 2), each program navigator reviewed the process maps. Adaptations in screening processes were identified, recorded and mapped to FRAME categories. Results: A total of 14 program navigators across 10 VHA lung cancer screening programs participated in 20 interviews. In year 1 (2019-2020), seven programs were operational and of these, three reported adaptations to their screening process that were either planned and in response to COVID-19. In year 2 (2020-2021), all 10 programs were operational. Programs reported 14 adaptations in year 2. These adaptations were both planned and unplanned and often triggered by increased workload; 57% of year 2 adaptations were related to identification and eligibility of Veterans and 43% were related to follow-up with Veterans for screening results. Throughout the 2 years, adaptations related to data management and patient tracking occurred in 6 of 10 programs to improve the data collection and tracking of Veterans in the screening process. Conclusions: Using FRAME, we found that adaptations occurred throughout the lung cancer screening process but primarily in the areas of patient identification and communication of results. These findings highlight considerations for lung cancer screening implementation and potential areas for future intervention.

Cooperative Extension Gets Moving, but How? Exploration of Extension Health Educators' Sources and Channels for Information-Seeking Practices.

PURPOSE: The Cooperative Extension System (Extension) has implemented concerted efforts toward health promotion in communities across the nation by acting as an intermediary between communities and universities. Little is known about how these intermediaries communicate and learn about existing evidence-based programming. This study serves to explore this gap by learning about information sources and channels used within Extension. DESIGN: Sequential explanatory mixed methods approach. SETTING: National Cooperative Extension System. PARTICIPANTS: Extension community-based health educators. METHODS: A nationally distributed survey with follow-up semistructured interviews. Survey results were analyzed using a Kruskal-Wallis 1-way analysis of variance test paired with Bonferroni post hoc. Transcripts were analyzed by conventional content analysis. RESULTS: One hundred twenty-one Extension educators from 33 states responded to the survey, and 18 of 20 invited participants completed the interviews. Educators' information seeking existed in 2 forms: (1) information sources for learning about programming and (2) channels by which this information is communicated. Extension educators reported contacting health specialists and other educators. Extension educators also reported using technological means of communication such as e-mail and Internet to reach information sources such as peers, specialists, academic journals, and so on. CONCLUSION: Extension state specialists were preferred as primary sources for intervention information, and technology was acknowledged as an easy contact channel. This study identifies county-based health educators' information structures and justifies the need for future research on the role of specialists in communication efforts for educators.

Evaluating "Take the Stairs, Wyoming!" Through the RE-AIM Framework: Challenges and Opportunities.

Introduction: Health promotion delivery systems are increasingly being asked to implement policy, systems, and environmental interventions (PSEs). However, evaluating PSEs is challenging, especially in low-resource community settings. This paper describes the use of RE-AIM to evaluate a physical activity PSE delivered through University of Wyoming Extension and highlights challenges and opportunities in pragmatic, real-world program evaluation. Methods: Extension health educators adapted a point-of-decision prompt intervention encouraging stairway use through posters, called Take the Stairs, Wyoming! Reach was assessed through estimates of daily traffic, effectiveness was assessed through opportunistic interviews, adoption was calculated as the number and proportion of sites that agreed to hang posters, implementation was calculated as the proportion of sites with a poster in place at a 2-weeks follow-up visit, and maintenance was assessed through 6-months opportunistic interviews (individual level) and proportion of sites with a poster in place (organizational level). Results: Overall, the posters were widely adopted and most posters were implemented as intended. However, capturing reach, effectiveness, and maintenance was challenging, as health educators found the evaluation burdensome. Therefore, it was difficult to determine if the posters were effective at increasing physical activity levels. Discussion: Suggestions are provided for capturing reach, effectiveness, and maintenance data in community settings. Future efforts are needed to create evaluation tools to pragmatically measure effectiveness of PSEs on changing behaviors, as well as to prioritize program evaluation in Extension.

Open-Access Physical Activity Programs for Older Adults: A Pragmatic and Systematic Review.

BACKGROUND AND OBJECTIVES: Open-access, community-based programs are recommended to assist older adults in meeting physical activity guidelines, but the characteristics, impact, and scalability of these programs is less understood. The Land-Grant University Cooperative Extension System, an organization providing education through county-based educators, functions as a delivery system for these programs. A systematic review was conducted to determine characteristics of effective older adult physical activity programs and the extent to which programs delivered in Extension employ these characteristics. RESEARCH DESIGN AND METHODS: A systematic review of peer-reviewed and grey literature was conducted from August 2016 to February 2017. The review was limited to open-access (available to all), community-based physical activity interventions for older adults (≥65 years of age). The peer-reviewed literature search was conducted in PubMed and EBSCOhost; the grey literature search for Extension interventions was conducted through Extension websites, Land-Grant Impacts, and the Journal of Extension. RESULTS: Sixteen peer-reviewed studies and 17 grey literature sources met inclusion criteria and were analyzed. Peer-reviewed and Extension programs were similar in their limited use of behavioral theories and group-based strategies. Compared to Extension programs, those in the peer-reviewed literature were more likely to use a combination of physical activity components and be delivered by trained professionals. DISCUSSION AND IMPLICATIONS: The results indicate notable differences between peer-reviewed literature and Extension programs and present an opportunity for Extension programs to more effectively use evidence-based program characteristics, including behavioral theories and group dynamics, a combination of physical activity components, and educator/agent-trained delivery agents.

National Working Group on the RE-AIM Planning and Evaluation Framework: Goals, Resources, and Future Directions.

The National Working Group on RE-AIM Planning and Evaluation Framework (herein Workgroup) was established in 2004 to support the application of the framework and advance dissemination and implementation science (D&I). Workgroup members developed and disseminated products and resources (and continue to do so) to advocate for consistent application of RE-AIM and allow for cross study comparisons. The purpose of this paper is to summarize key Workgroup activities, products, and services (e.g., webinars, consultations, planning tools) and enhance bidirectional communication between the Workgroup and RE-AIM users. The ultimate goal of this work is to serve as a forum for dissemination to improve the balance between RE-AIM user demand (needs) and the currently limited RE-AIM Workgroup supply (consultation and resources) to demonstrate and expand the utility of RE-AIM as a D&I planning and evaluation framework. A summary of resources is provided as well as specific examples of how the Workgroup has been responsive to user needs.

Beginning With the End in Mind: Contextual Considerations for Scaling-Out a Community-Based Intervention.

Introduction: A number of effective physical activity programs for older adults exist, but are not widely delivered within community settings, such as the Cooperative Extension System. The purpose of this paper was to determine if an evidence-based intervention (EBI) developed in one state Extension system could be scaled-out to a new state system. Methods and results: The RE-AIM (reach, effectiveness, adoption, implementation, maintenance) framework was used to guide an iterative evaluation of three translational stages. Stage 1: Before program adoption, Extension health educators were surveyed and interviewed to assess physical activity programming perceptions and factors that may influence their decision to attend training or deliver the program in practice. Results indicated that a virtual, scalable training protocol would be necessary and that training needed to include hands-on instruction and be catered to those who were less confident in physical activity program delivery. Stage 2: Training attendees were surveyed pre- and post-training on factors related to the adoption-decision making process and contacted post-training to assess program delivery status. Training did not influence perceptions of the program, intent to deliver, or confidence in delivering the program. Stage 3: During program implementation, the program was evaluated through the RE-AIM framework by surveying across three key stakeholder groups: (1) program participants, (2) potential delivery personnel, and (3) Extension administrators. Findings indicate that the program has the potential to reach a large and representative proportion of the target audience, especially in rural areas. However, adoption and implementation rates among Extension health educators and community partners were low and data collection for effectiveness, implementation, and maintenance was a challenge. Conclusion: Overall, the results indicate initial struggles to translating and evaluating the program in a large, rural state. Implications for practice include making system-level changes to increase physical activity program adoption rates among Extension health educators and improve data collection and program evaluation through this community-based organization. More work is needed to identify infrastructure support and capacity to scale-out EBIs.

Informed Adaptations of a Strength-Training Program through a Research-Practice Partnership.

Efficacy and effectiveness data for strength-training programs targeting older adults have been well established, but it is evident that they are not translated within practice-based settings to have a public health impact, as most (~90%) older adults are not meeting strength-training recommendations. Strength-training interventions developed, delivered, and evaluated in highly controlled settings (e.g., eligibility requirements, certified instructor, etc.) may not reflect real-world needs. One strategy to improve these outcomes is to work through an integrated research-practice partnership (IRPP) to plan and evaluate an intervention to better fit within the intended delivery system. The purpose of this study was to describe the IRPP method by which academic and practice representatives can partner to select and adapt a best-fit strength-training program for older adults. This work was planned and evaluated using the reach, effectiveness, adoption, implementation, and maintenance framework, applying the AIM dimensions to complement the methodology of the partnership. In this pragmatic work, members of the IRPP adapted the evidence-based program, Stay Strong, Stay Healthy (SSSH) into a new program, Lifelong Improvements through Fitness Together (LIFT). Of the health educators who agreed to be randomized to deliver LIFT or SSSH (N = 9), five were randomized to SSSH and four were randomized to deliver LIFT. Fifty percent of educators randomized to SSSH delivered the program, whereas 80% of the health educators randomized to LIFT delivered the program. The health educators deemed LIFT more suitable for delivery than SSSH, self-reported high rates of fidelity in program delivery, and intended on delivering the program in the following year. In conclusion, this study provides transparent methods for using an IRPP to adapt an intervention as well as preliminary outcomes related to adoption, implementation, and maintenance.

Use of an Integrated Research-Practice Partnership to Improve Outcomes of a Community-Based Strength-Training Program for Older Adults: Reach and Effect of Lifelong Improvements through Fitness Together (LIFT).

Only 17% of older adults meet the recommendations for two days of full body strength training that is associated with improved functional fitness; reduced risk of falls; and reduced morbidity and mortality rates. Community-based interventions are recommended as they provide supportive infrastructure to reach older adults and impact strength training behaviors. Scalability and sustainability of these interventions is directly linked with setting-level buy-in. Adapting an intervention through an integrated research-practice partnership may improve individual and setting-level outcomes. The purpose of this study was to evaluate the initial reach and effect of a locally adapted, health educator-led strength-training intervention; Lifelong Improvements through Fitness Together (LIFT). LIFT was compared to an evidence-based exercise program, Stay Strong; Stay Healthy (SSSH). Intervention dose and mode were the same for LIFT and SSSH, but LIFT included behavioral change strategies. Older adult functional fitness was assessed before and after the 8-week strength training intervention. Health educators who delivered LIFT and SSSH were able to reach 80 and 33 participants, respectively. Participants in LIFT were able to significantly improve in all functional fitness measures whereas SSSH participants were only able to significantly improve in 5 of the 7 functional fitness measures. In conclusion, this study provides preliminary evidence that the locally adapted program reached more individuals and had improvements in functional fitness.