The Robert Wood Johnson Foundation Diabetes Initiative: demonstration projects emphasizing self-management.

PURPOSE: The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings. METHODS: The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States. This report describes the Initiative, its ecological perspective on self-management, and implications for program development, sustainability, and dissemination. RESULTS: Ecological perspectives stress varied levels of influence ranging from individuals to communities and policies. Based on this, the Initiative has identified key resources and supports for self-management (individualized assessment, collaborative goal setting, enhancing skills, follow-up and support, community resources, and continuity of quality clinical care). Lessons learned include the central roles of community health workers, integration of healthy coping and attention to negative emotion and depression in self-management, community partnerships, approaches to ongoing follow-up and support, organizational factors in sustaining programs, and the utility of a collaborative learning network for program development. Sustainability stresses organizational and policy supports for the program. Dissemination of lessons learned will stress collaboration among interested parties, stimulating consumer understanding and demand for self-management services as central to diabetes care. CONCLUSIONS: The Diabetes Initiative demonstrates that effective self-management programs and supports can be implemented in real-world clinical and community settings, providing models of worthwhile, sustainable programs.

A community-based approach to promoting walking in rural areas.

BACKGROUND: Ecologic models are often recommended to promote physical activity, yet sparse data exist on their effectiveness. DESIGN: A quasi-experimental design examined changes in walking behavior in six rural intervention communities in the Missouri "bootheel" region and in six comparison communities in Arkansas and Tennessee. SETTING/ PARTICIPANTS: The communities ranged in population from 2399 to 17,642; interventions focused on adults aged >/=18 years. INTERVENTION: Interventions were developed with community input and included individually tailored newsletters, interpersonal activities that stressed social support, and community-wide events such as walk-a-thons. MAIN OUTCOME MEASURES: Primary outcomes were rates of walking-trail use, total number of minutes walked in the past week, and total minutes walked for exercise. RESULTS: Among persons who used trails at baseline (16.9% of the total population), 32.1% reported increases in physical activity since they began using the trail. From community-wide samples, two subgroups indicated a positive net change in rates of 7-day total walking: people with high school degrees or less and people living in households with annual incomes of <==$20,000. However, no studied group showed a statistically significant net intervention effect. CONCLUSIONS: Although there was an increase in the rate of walking-trail use, a community-wide change in walking rates in rural communities was not documented. Results of this study should provide guidance for future projects.

The epidemiology of walking for physical activity in the United States.

PURPOSE: The purpose of this paper was to describe the epidemiology of walking for physical activity among respondents to the U.S. Physical Activity Study. Correlates of walking among people who never walk for physical activity, those who walk regularly, and people who walk occasionally were compared. METHODS: Data on walking, personal and environmental correlates, and sociodemographics were collected via telephone using a modified random-digit-dialing technique on a national sample. Three categories were analyzed: Regular walkers were those who met public health recommendations by walking (5x wk-1 and 30 min at a time), occasional walkers were those who walked for physical activity but did not meet this recommendation, and never walkers were those who never walked for physical activity. Multiple logistic regression resulting in odds ratios (OR) and 95% confidence intervals were calculated. RESULTS: Thirty-four percent of this population were regular walkers, 45.6% occasional walkers, and 20.7% never walkers. Walkers reported using neighborhood streets, shopping malls, and parks for walking. Regular walkers had more self-confidence and more social support than occasional or never walkers. Occasional and never walkers reported time as a barrier more than regular walkers (OR 1.91 and 2.36). Never walkers were more likely (OR 3.25) to report feeling unhealthy and more likely (OR 4.43) to report lacking energy to exercise. CONCLUSION: Our results identify important information that can be used to help guide future interventions that promote walking as a form of physical activity. An ecological approach that combines individual (e.g., self-confidence), interpersonal (e.g., social support), and community aspects (e.g., improve streets for walking) may be the most beneficial.

Process evaluation of a monitoring log system for community coalition activities: five-year results and lessons learned.

PURPOSE: Coalitions can be a successful way to promote healthy initiatives throughout a community. To properly measure the success of coalition-based interventions, it is important to conduct a process evaluation of coalition activities and establish a system for evaluating outcomes. This article describes a process evaluation of a monitoring and feedback system for community coalitions targeting chronic disease risk reduction. METHODS: Community coalitions in six rural, southeast Missouri counties collaborated with the Missouri Department of Health and Saint Louis University to track coalition events using the process described in the Centers for Disease Control and Prevention manual Evaluating Community Efforts to Prevent Cardiovascular Diseases. SUMMARY: First, we describe the methodology used to monitor monthly activities and to evaluate satisfaction with the process. Next, we discuss the data that resulted from the monitoring system and interviews with recorders. Third, we discuss changes made to the monitoring system and lessons learned along the way. Finally, we end with recommendations for incorporating this monitoring system in community practice. CONCLUSIONS: When used properly, this system is an effective way of evaluating and promoting sustainability of community interventions.