Authors: Mickey Bolyard*+, Shannon Jones, Amy Loverin, Madeleine French, Josh Christensen, and Paul Estabrooks+
*: presenting author
+: corresponding authors

Purpose: There is limited information on the dissemination of evidence-based type 2 diabetes prevention interventions focusing on youth. The purpose of this presentation is to describe changes in workflow and potential intervention adaptation to support the dissemination of Team Thrive—an effective type 2 diabetes risk reduction intervention for high school students.

Methods: We initiated a workflow analysis of Team Thrive to determine intervention adaptation and dissemination across phases of (1) researcher implementation within a cluster randomized controlled trial, (2) initial dissemination to local schools, and (3) current dissemination to local schools. Specifically, we completed the first two steps of workflow analysis that included orientation through group (n=3) and individual interviews (n=4) with Team Thrive developers and managers, as well as observation of current dissemination strategies.

Findings: Components of Team Thrive that were consistent across the RCT and dissemination phases included (1) 6 lessons delivered over 2 to 3 weeks that focused on physical activity, fruits and vegetables, and added sugars, (2) student goal selection, (3) team activities with students of like goals, and (4) friendly competition. Transitioning from research to teacher implementation resulted in changes to Team Thrive technology components (i.e., step counters and objective carotenoid screening were not provided), and peer mentoring with university students was not proactively facilitated. The initial dissemination workflow included partnership with the state board of education, use of teacher list serves, teacher request for the curriculum, access to the curriculum and a teacher implementation manual on Google Drive, and printed copies of the curriculum. Workflow was changed to include teacher registration and teacher training videos. Across these phases, Team Thrive was delivered to 6 schools as part of the RCT and disseminated to 72 and 57 new schools during the initial and current phases. Reflection with dissemination staff indicated that the optimal workflow would include changes to data collection protocol, recordkeeping, and program metrics to improve program evaluation and adaptation.

Conclusions: Team Thrive appears to be a highly scalable approach for high school diabetes prevention, though assessment of implementation quality and effectiveness with reported adaptations is needed.

Purpose: Physical activity (PA) confers benefits across the lifespan, but most Americans do not meet PA Guidelines. Multiple consensus documents, reports, and guidelines exist that identify research, policy, and practice knowledge gaps (we define as opportunities). Several of the opportunities to address knowledge gaps may be important considerations for communities experiencing health inequities. The goal of this study was to synthesize and categorize opportunities into a conceptual framework for potential use by funders, researchers, policymakers, and practitioners to advance PA promotion.

Methods: The National Collaborative on Childhood Obesity Research convened subject matter experts to 1) identify source documents published by government or national non-profit organizations related to PA promotion, 2) review documents to extract research, policy and practice opportunities, 3) code the opportunities by translational phase, intervention level, setting, and priority population, 4) synthesize data on similar opportunities, and 5) review the list of condensed opportunities, including those with a health equity focus, to develop the framework.

Results: Opportunities (n=431) were extracted from sources (n=11) and combined into condensed opportunity statements (n=96) that called for effectiveness research (n=47, 49%) and dissemination/implementation research and practice (n=21, 22%). Forty-three percent were related to policy, systems, or environment (PSE) interventions (n=41) and 69% mentioned community settings (n=66). Additionally, 76% mentioned populations across the lifespan (n=73) and twenty-two statements (23%) included health equity considerations. The resultant outcome was a framework detailing opportunities by translational research phase (measure development, etiology, efficacy, effectiveness, dissemination and implementation, and surveillance) and intervention level (individual or interpersonal, PSE, and crosscutting), including health equity considerations.

Conclusions: The resultant framework reveals opportunities for PA funders, researchers, policymakers, and practitioners to strategically advance their work. The results also highlight gaps in current evidence. There are opportunities for work across translational science phases (beyond effectiveness) to use community- and practitioner-engaged approaches, establish efficacious interventions while designing for dissemination and implementation, and develop strategies for improving dissemination and implementation. Opportunities also exist to address health equity by tailoring interventions, enhancing reach to priority populations, and improving social determinants of health.

Disclaimer: This abstract does not represent the official position of the CDC.

Purpose: International recommendations identify health professionals as pivotal agents to tackle physical inactivity. This study aimed to characterize medical doctors’ clinical practices concerning the promotion of patients’ physical activity and explored potential predictors of the frequency and content of these practices.

Methods: A cross‐sectional study assessed physical activity promotion in clinical practice with a self‐report questionnaire delivered through the national medical prescription software (naturalistic survey). Medical doctors’ physical activity and sedentary behaviours were estimated using the International Physical Activity Questionnaire (short form). Indicators of their attitudes, knowledge, confidence, barriers, and previous training concerning physical activity promotion targeting their patients were also assessed. Multiple regression analysis was performed to identify predictors of physical activity promotion frequency by medical doctors, including sociodemographic, attitudes and knowledge‐related variables, and physical activity behaviours as independent variables.

Results/findings: A total of 961 medical doctors working in the Portuguese National Health System participated (59% women, mean age 44 ± 13 years) in the study. The majority of the participants (84.6%) reported to frequently promote patients’ physical activity. Five predictors of physical activity promotion frequency emerged from the multiple regression analysis, explaining 17.4% of the dependent variable (p < 0.001): working in primary healthcare settings (p = 0.037), having a medical specialty (p = 0.030), attributing a high degree of relevance to patients’ physical activity promotion in healthcare settings (p < 0.001), being approached by patients to address physical activity (p < 0.001), and having higher levels of physical activity (p = 0.001).

Conclusions: The sample of medical doctors approached reported a high level of engagement with physical activity promotion. Physical activity promotion frequency among medical doctors seems to be higher when working in primary care setting, having a medical specialty, having positive attitudes towards physical activity, when perceiving patients ́ interest on the topic, and when having higher physical activity levels.

Purpose: Healthy Eating and Active Living Taught at Home (HEALTH) embeds healthy eating and activity content within Parents as Teachers (PAT), a national home visiting program. This secondary analysis aims to understand the factors that predict intention to deliver HEALTH and the self-efficacy of parent educators (home vising program providers) to deliver HEALTH.

Methods: This is a cross-sectional, analysis of baseline data from a trial evaluating the effectiveness of HEALTH when delivered by parent educators as part of usual practice. Parent educators completed surveys following training in the HEALTH intervention; demographic characteristics (including self-reported body mass index) were collected in a baseline survey (pre-training). Surveys were based on two implementation science frameworks: Consolidated Framework for Implementation Research (CFIR, implementation context) and Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM, implementation outcomes). Associations between intent to deliver HEALTH (intent) and self-efficacy (SE) to deliver HEALTH, implementation context constructs and demographic characteristics were explored using Pearson correlations (continuous variables) and t-tests (binary variable). Relationships were considered significant if the p value was less than 0.05.

Results/findings: Among the 149 parent educators who completed the survey, just over half identified as white/non-Hispanic (53%), while just over a third identified as Hispanic. Participants reported having worked at their site for a mean of 4.7 years (standard deviation, SD=5.85), and the mean body mass index was 30.43 kg/m2 (SD=7.35). There was a significant correlation between intent and SE, r=0.46 (<.0001). Most demographic characteristics (e.g., body mass index, age) were not significantly correlated with either variable, however, intent and SE were both significantly lower among white non-Hispanic parent educators than among those identifying as another race/ethnicity. Several other implementation context constructs such as evidence strength and quality, fit, appeal, openness, and relative advantage were positively correlated with both intent and SE; complexity was negatively correlated.

Conclusions: When implementing healthy eating and activity content within community settings, it is important to consider what factors may be related to provider intent and provider self-efficacy to deliver the content.

Purpose: Measuring implementation fidelity is crucial, yet it proves challenging. While observational methods are considered the gold standard, their practicality in community settings is restricted by resource constraints. The purpose of this study is to report on a capacity building initiative that trained direct observers from local communities to conduct fidelity assessments of an evidence-based, family healthy weight program (FHWP), Building Healthy Families (BHF).

Methods: We developed an implementation fidelity assessment for a hybrid type III implementation effectiveness pilot to translate a FHWP into medically underserved areas. Community direct observers were recruited locally and trained by an expert observer to assess weekly BHF sessions. Trainings occurred virtually to familiarize observers with the fidelity assessment process and tools by reviewing previously recorded community sessions. Training fidelity assessments were scored against the expert observer, with >85% agreement required for independent observation. Weekly research meetings were attended by community direct observers to provide an overview of sessions and unique components of fidelity not captured by the assessments. Percent agreement was assessed quantitatively while community direct observer perceptions were gathered qualitatively through meeting notes.

Results/Findings: Community direct observers (n=5) were hired and trained to conduct fidelity assessments across 7 communities. All observers reached >85% agreement with the expert observer by their second session and were able to observe community BHF sessions independently. Community direct observers were able to complete all assigned assessments that included 42 sessions in Cohort 1 (n=7 communities), 17 sessions in Cohort 2 (n=5 communities), and 3 sessions in Cohort 3 (n=1 community). The collaborative involvement of local observers with the research team fostered community engagement and provided key insights into implementation of a FHWP which otherwise would have been unknown to researchers. Local direct observers were also successful at gathering information on BHF adaptations, both positive and negative, across program sessions.

Conclusions: Building local capacity for direct observation was successful in this study. This approach not only enhances the feasibility of measuring implementation fidelity, but also establishes a model for ongoing assessments, contributing to the effective translation of FHWP into diverse settings and potential impact of BHF.

Purpose: Produce prescription programs show promise for improving dietary intake and health but there is a lack of detailed process and implementation evaluation data available. We will present process and implementation evaluation of the Brighter Bites/UT Physicians Produce Rx.

Methods: The Brighter Bites/UT Physicians Produce Prescription Program uses a comparative effectiveness RCT design to evaluate two produce prescription strategies to improve obesity-related health outcomes and dietary behaviors among 150 low-income children aged 5-12 years with overweight/obesity from two pediatric clinics in Houston, Texas. Participants are randomized into one of three arms: 1) Bi-weekly $25 produce vouchers to local grocery stores(n=50), 2) Bi-weekly produce delivery(n=50), or 3) waitlist controls(n=50). Process and implementation evaluation data are collected through pre-/post-program surveys, pulse surveys (participants), implementation surveys, qualitative interviews, EHR review, and program administrative review.

Results/Findings: A total of 150 children participated in the CE-RCT; mean age 9.0 years, 47.9% Hispanic, 45.3% African American. Process evaluation measures include produce variety and quantity; nutrition education distributions; enrollment; acceptability/satisfaction regarding access to produce, nutrition education, cultural appropriateness; clinic staff satisfaction; and produce/voucher value costs. Using the RE-AIM framework, we are assessing Reach (demographics of eligible patients at clinics, demographics of patients prescribed to program, demographics of patients consented and enrolled); Effectiveness (food security, nutrition security, diet quality, changes in biomarkers: BMI, weight, blood pressure, hemoglobin A1c, AST ALT, and lipid panels are presented elsewhere); Adoption (number of physicians trained in prescribing program, number and percentage of physicians who prescribe program); Implementation (program level - number of boxes delivered, pounds of FV delivered, number vouchers delivered, vouchers reissued, number families not receiving weekly distributions; participant level - number vouchers received, % vouchers activated, % vouchers redeemed, dollar amount vouchers redeemed, date vouchers redeemed, number patients who receive nutrition education tips). All analysis will be complete in Spring 2024.

Conclusions: Process and implementation data on produce prescription programs is critical for replicability and scalability of produce prescription programming. These types of studies are also critical for establishing value and return on investment to justify funding for produce prescription programs, and to inform future programming and research.

Purpose: This study extends previous research on the Family Nutrition and Physical Activity (FNPA) screening tool by developing and testing threshold values that may provide clinical risk zones to identify youth at greater risk for overweight.

Methods: Clinical data were obtained from annual well-child visits within the Geisinger Health System spanning the years 1999 to 2022. The sample was restricted to individuals with at least one record of FNPA in early childhood (2 – 5 years old); no record of being overweight/obese before the age of 5 (i.e., BMI < 85th percentile); and at least one record of BMI within the follow-up period (6 – 12 years old). Weight status was classified as normal weight if the recorded BMI values remained below the 85th percentile or overweight/obese if BMI was ever recorded to be greater than the 85th percentile. An ordinal logistic regression model was built for the weight status variable with factors including gender, race, ethnicity, early childhood BMI group (<5%, 5-50%, 50-85%), insurance status (public/private), and FNPA score. The Weight of Evidence method was employed to derive thresholds of FNPA scores that differentiated risk of becoming overweight during the 6-year follow-up period. ROC analysis and Hosmer-Lemeshow tests assessed the goodness of fit and the predictive utility of the thresholds.

Results/Findings: The final sample included 7226 participants (51.3% male, 81.4% white, and 40.8% with private insurance). The average length of follow-up from baseline was 3.04 (±1.91) years with 23.4% of the males and 20.6% of females classified as overweight or obese in the follow-up period. A significant negative coefficient in the regression model confirmed that a higher FNPA score was associated with a lower probability of developing overweight or obesity. The prevalence of being overweight or obese was highest in the low FNPA group (FNPA < 63) and lowest in the high FNPA group (FNPA > 67). The ROC analyses demonstrated utility of the thresholds for discriminating risk of overweight with area under the curve (AUC) values > 0.66.

Conclusion: The results support the predictive utility of the FNPA for identifying potential risk of overweight/obesity during childhood.

Purpose:
Eating Competence (EC) is an adaptive and inclusive eating style defined by the Satter Eating Competence Model (ecSatter) and described by four domains: food management/contextual skills, internal cues, food acceptance, and eating attitudes. Higher EC is associated with higher quality diets and physical activity levels, and better biomedical and psychosocial indicators. Daily Hassles are small nuisances of daily living, and when they occur frequently, they can impair health outcomes. It is unknown how life course events (i.e., pregnancy, child-rearing) and daily hassles predict EC across the life course. The aim of this study is to create a registry of individuals that can be used in future longitudinal studies to assess the relationship between EC, life course events, and daily hassles. No such registry exists, and no previous studies have examined EC longitudinally.

Methods:
This study is being completed in three phases, and the project is currently in Phase II. For Phase I, a ~100-item survey was developed that includes the EC Satter Inventory (ecSI 2.0™), the Daily Hassles and Uplifts Scale (DHUS); and demographics, social identities, caregiving status, and other reasons people may tailor their diets. Focus groups were used to refine questions and pilot-test survey completion. Phase I results informed Phase II, which is to recruit a convenience sample of undergraduate students in various nutrition courses offered in 2023-2024 at the researchers’ university, allowing for further survey refinement. Phase III will be to recruit a registry of participants from college courses across the U.S. and follow-up with repeated surveys every two years. All survey data is collected using REDCap™ software and will be analyzed using SPSS.

Results/Findings:
Phase II recruitment is underway. To date, we have demonstrated the ability to enroll 479 undergraduate students in the Lifecourse Eating and Feeding Registry.

Conclusions:
A registry of participants is the first step to exploring how EC changes over time and how life course events and daily hassles influence these changes. Results will help better predict changes in eating behaviors and identify factors for future intervention.

Authors
Hollyanne Fricke, MPH (presenting, corresponding)
Gretchen Groves, RDN
Ka Her, MPH
Carmen Byker Shanks, PhD, RDN
Bailey Houghtaling, PhD, MSc, RDN
Amy Yaroch, PhD

Title
Lessons Learned and Future Directions for Technical Assistance within Financial Incentive Programs Designed to Increase Fruit and Vegetable Intake across the United States

Purpose
Since 2019, the Gus Schumacher Nutrition Incentive Program (GusNIP) NTAE Center (Nutrition Incentive Program Training, Technical Assistance, Evaluation, and Information Center) has served as a coordinating center to provide implementation and evaluation technical assistance (TA) to projects designed to provide financial incentives aimed at increasing fruit and vegetable intake among populations with low income throughout the United States (US). These nutrition incentive and produce prescription projects are required to contribute to a dataset of shared measures so that the NTAE Center can report aggregate impacts.

Methods
The NTAE Center has taken an iterative and responsive approach to the provision of technical assistance within GusNIP, driven predominantly by expressed project needs. Specific to evaluation, the NTAE Center has developed a suite of 1:1, group, and centralized advising opportunities to aid projects in meeting robust requirements. Further, those looking to apply for a GusNIP grant are given a unique opportunity to interface with the NTAE Center during the application process, such that they are familiar with requirements up front, thereby increasing competitiveness of their application.

Results/Findings
Comprehensive evaluation technical assistance builds GusNIP project capacity to better understand and fulfill grant requirements and ultimately produces higher-quality data to demonstrate project and overall program impacts to grow the financial incentives field and sustain funding. From 2019-2023, the NTAE Center identified best practices for evaluation technical assistance including: creating a TA model with a dynamic menu of options; tailoring TA by project type and organizational capacity for evaluation; and designing evaluation approaches that balance grant requirements, scientific rigor, project capacity, and overlay diversity, equity, and inclusion practices. In its next four years and beyond, the NTAE Center’s TA model will be guided by a “learning circle” advisory group (including projects, as well representatives from the intended low-income population across diverse US geographic regions) and aligned with implementation science theories, models, and frameworks.

Conclusions
Lessons learned from the GusNIP NTAE Center can be applied by other organizations or coordinating centers providing evaluation-related technical assistance within large-scale, multi-year, and/or multi-site programs across the US or potentially as translated to other countries.

Purpose: The Wellness Bus (WB) is a mobile health unit that provides screening, health coaching, and referral to community resources for underserved communities in the Salt Lake Valley. As part of the Connect Diabetes Prevention Program (DPP) Pilot Study, the purpose of this presentation is to document themes and actions to support increased participation of future visitors to the WB.

Methods: We conducted 10 qualitative interviews with visitors (80% Hispanic/Latino) to the WB who screened in the pre-diabetes range. All interviews were transcribed, reduced to meaning units, and then inductively coded by two research team members to identify themes, subthemes, and valence (i.e., positive or negative influence on enrollment) related to DPP enrollment. Themes and subthemes were reported based on their relationship with potential enrollment.

Results: Across interviews, four primary themes were identified—accessibility, experiences with WB staff, participant characteristics, and strategies to improve WB services. Accessibility included subthemes related to affordability (positive, if insured; negative if not), program delivery location (positive when completed on the WB; negative otherwise), Spanish health education materials (positive for spoken language; negative for overall signage), program structure and schedule (positive for virtual; negative for work hour programs), and awareness of available programming (variable awareness of available programs). WB visitor experience with the WB staff indicated positive perceptions of the information provided, motivational support, languages spoken, and referrals to resources (though this was variable across interviewees).
Factors related to the WB visitor included motivation to change (high for those that enrolled in DPPs; low for those that did not), perceptions of risk (high for those that enrolled in DPPs; low for those that did not) and competing demands (lower for those that enrolled in DPPs; higher for those that did not). Finally, participants identified partnering with community organizations to improve marketing of WB resources, more consistent referrals to local resources, outreach and follow-up from WB staff, and co-location of DPPs with the WB as ways to improve WB impact.

Conclusions: Novel ideas for better outreach, co-location of programming, and other participant-identified strategies to improve WB outcomes were identified.