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INTRODUCTION: Online Diabetes Prevention Programs (DPPs) can be scaled up and delivered broadly. However, little is known about real-world effectiveness and how outcomes compare with in-person DPP. This study examined online DPP weight loss and participation outcomes and secondarily compared outcomes among participating individuals with parallel in-person interventions. STUDY DESIGN: A large non-randomized trial supplemented by a comparative analysis of participating individuals from a concurrent trial of two parallel in-person programs: in-person DPP and the Veterans Administration's standard of care weight loss program (MOVE!). SETTING/PARTICIPANTS: Obese/overweight Veterans with prediabetes enrolled in online DPP (n = 268) between 2013 and 2014. Similar eligibility criteria were used to enroll in-person participants between 2012 and 2014 (n = 273 in-person DPP, n = 114 MOVE!) within a separate trial. INTERVENTION: Online DPP included a virtual group format, live e-coach, weekly modules delivered asynchronously, and wireless home scales. In-person programs included eight to 22 group-based, face-to-face sessions. MAIN OUTCOMES MEASURES: Weight change at 6 and 12 months using wirelessly uploaded home scale data or electronic medical record weights from clinical in-person visits. Outcomes were analyzed between 2015 and 2017. RESULTS: From 1,182 invitations, 268 (23%) participants enrolled in online DPP. Among these, 158 (56%) completed eight or more modules; mean weight change was -4.7kg at 6 months and -4.0kg at 12 months. In a supplemental analysis of participants completing one or more sessions/modules, online DPP participants were most likely to complete eight or more sessions/modules (87% online DPP vs 59% in-person DPP vs 55% MOVE!, p < 0.001). Online and in-person DPP participants lost significantly more weight than MOVE! participants at 6 and 12 months; there was no significant difference in weight change between online and in-person DPP. CONCLUSIONS: An intensive, multifaceted online DPP intervention had higher participation but similar weight loss compared to in-person DPP. An intensive, multifaceted online DPP intervention may be as effective as in-person DPP and help expand reach to those at risk.

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BACKGROUND: Physical exercise confers many health benefits, but it is difficult to motivate people to exercise. Although community exercise groups may facilitate initiation and persistence in an exercise program, reports regarding factors that allow such groups to flourish are limited. OBJECTIVES: We performed a prospective qualitative evaluation of our experience starting a program of community-based, peer-led exercise groups for military veterans to identify important lessons learned. METHODS: We synthesized data from structured observations, post-observation debriefings, and focus groups. Our participants were trained peer leaders and exercise group members. Our main outcomes consisted of empirically derived lessons learned during the implementation of a peer-led group exercise program for veterans at multiple community sites. We collected and analyzed data from 40 observation visits (covering 14 sites), 7 transcribed debriefings, and 5 focus groups. RESULTS: We identified five lessons learned. (1) The camaraderie and social aspect of the exercise groups provided motivation for people to stay involved. (2) Shared responsibility and commitment to each other by the group members was instrumental to success. (3) Regular meeting times encouraged participation. (4) Variety, especially getting outdoors, was very popular for some groups. (5) Modest involvement of professionals encouraged ongoing engagement with the program. CONCLUSIONS: Both social and programmatic issues influence implementation of group exercise programs for older, predominantly male, veterans. These results should be confirmed in other settings.

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OBJECTIVES: To assess whether the effects of community-based educational interventions to improve blood pressure, weight and health behaviours benefit participants with lower educational levels more than those with higher educational levels. DESIGN: Secondary data analysis. SETTING: Two 12-month community-based educational interventions, one led by trained peers and one delivered by health professionals. PARTICIPANTS: A total of 403 hypertensive individuals, grouped by education (high school or less; 1-3 years college; 4 + years college). MAIN OUTCOME MEASURES: Blood pressure, weight, physical activity and fruit and vegetable intake. RESULTS: We found that changes in blood pressure, weight and physical activity were similar across education levels; college graduates consumed more daily servings of fruits and vegetables at baseline (3.7 versus 3.6 for those with 12-15 years and 3.1 for those with < 12 years, p = 0.0112), and increased intake more after the intervention (+0.4 versus -0.1 and -0.1, p = 0.0142). The two methods of delivery - peer-led versus professional - had similar effects on all measures. CONCLUSIONS: We conclude that educational interventions, whether delivered by peers or professionals, may improve chronic disease self-management among participants but do not confer greater benefits on participants with lower educational levels.

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Individuals reporting high group cohesion are less likely to discontinue participation in group exercise programs. A validated measure of group cohesion, the Physical Activity Group Environment Questionnaire (PAGEQ), is untested in older men. The PAGEQ was administered to, and questions about demographics and frequency and duration of participation were asked of, the Walk A Mile or More (WAMM) exercise group, which was composed of U.S. military Veterans. Forty participants (mean age = 62 years, 77.5% male) completed surveys. Cronbach's alpha for the overall PAGEQ was 0.976. Although no significant relationship was found between group cohesion scores and frequency of attending WAMM sessions, there was a trend for individuals who had participated for a longer time to report more group cohesiveness, particularly regarding the task (i.e., exercise) itself. The PAGEQ was easily administered and internally consistent in this group of older men, and provides a useful benchmark for future gerontological researchers. [Journal of Gerontological Nursing, 42(8), 18-23.].

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BACKGROUND: Diabetes prevention is a national goal and particularly important in the Veterans Health Administration (VHA) where 1 in 4 veterans has diabetes. There is growing evidence to support the use of Web-based diabetes prevention program (DPP) interventions, shown to be as effective and often more feasible than in-person interventions. OBJECTIVE: Our primary objective was to qualitatively explore women veterans' early experiences with a Web-based DPP intervention. Our secondary objective was to estimate weight loss, participation, and engagement to provide context for our qualitative findings. METHODS: We conducted and analyzed semistructured interviews and collected data on weight change, participation, and engagement. A total of 17 women veterans with prediabetes from a Midwest VA Women's Health Clinic were eligible to participate; 15 completed interviews. RESULTS: Participants perceived the DPP program as an appealing way of initiating lifestyle changes and made them feel accountable in achieving their daily goals. The online program was convenient because it could be accessed at any time, and many found that it integrated well into daily life. However, some did not like the logging aspect and some found it to be too impersonal. Participants logged in a mean 76 times, posted a mean 46 group messages, and sent a mean 20.5 private messages to the health coach over 16 weeks. Participants lost 5.24% of baseline weight, and 82% (14/17) of participants completed at least 9 of 16 core modules. CONCLUSIONS: Women veterans' early experiences with a Web-based DPP intervention were generally positive. Accountability and convenience were key enabling factors for participation and engagement. A Web-based DPP intervention appears to be a promising means of translating the DPP for women veterans with prediabetes.

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BACKGROUND: Peer-led interventions to improve chronic disease self-management can improve health outcomes but are not widely used. Therefore, we tested a peer-led hypertension self-management intervention delivered at regular meetings of community veterans' organizations. METHODS: We randomized 58 organizational units ("posts") of veterans' organizations in southeast Wisconsin to peer-led vs. professionally delivered self-management education. Volunteer peer leaders at peer-led posts delivered monthly presentations regarding hypertension self-management during regular post meetings. Volunteer post representatives at seminar posts encouraged post members to attend 3 didactic seminars delivered by health professionals at a time separate from the post meeting. Volunteers in both groups encouraged members to self-monitor using blood pressure cuffs, weight scales, and pedometers. Our primary outcome was change in systolic blood pressure (SBP) at 12 months. RESULTS: We measured SBP in 404 participants at baseline and in 379 participants at 12 months. SBP decreased significantly (4.4mm Hg; P < 0.0001) overall; the decrease was similar in peer-led and seminar posts (3.5mm Hg vs. 5.4mm Hg; P = 0.24). Among participants with uncontrolled BP at baseline, SBP decreased by 10.1mm Hg from baseline to 12 months but was again similar in the 2 groups. This pattern was also seen at 6 months and with diastolic blood pressure. CONCLUSIONS: Our peer-led educational intervention was not more effective than didactic seminars for SBP control. Although peer-led educational programs have had important impacts in a number of studies, we did not find our intervention superior to a similar intervention delivered by healthcare professionals. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov NCT00571038.

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Volunteer peer leaders (PLs) benefit from their involvement in health interventions but we know little about how they compare with other non-PL volunteers or with the intervention recipients themselves. We randomized 58 veterans' service organizations' posts (e.g. VFW) to peer- versus professionally led self-management support interventions. Our primary research questions were whether hypertensive PLs changed over the course of the project, whether they changed more than hypertensive volunteers who were not randomized to such a role [i.e. post representatives (PRs)] and whether they changed more than the intervention recipients with respect to health knowledge, health beliefs and health outcomes from baseline to 12 months. After the intervention, PLs provided open-ended feedback and participated in focus groups designed to explore intervention impact. Hypertensive PLs improved their systolic blood pressure and hypertension knowledge and increased their fruit/vegetable intake and pedometer use. We found no differences between PLs and PRs. PLs improved knowledge and increased fruit/vegetable intake more than intervention recipients did; they provided specific examples of personal health behavior change and knowledge acquisition. Individuals who volunteer to be peer health leaders are likely to receive important benefits even if they do not actually take on such a role.

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Hypertension knowledge is an integral component of the chronic care model. A valid scale to assess hypertension knowledge and self-management skills is needed. The hypertension evaluation of lifestyle and management (HELM) scale was developed as part of a community-based study designed to improve self-management of hypertension. Participants included 404 veterans with hypertension. Literature review and an expert panel were used to identify required skills. Items were generated and pilot tested in the target population. Validity was assessed through comparisons of performance with education, health numeracy, print numeracy, patient activation and self-efficacy, and hypertension control. The HELM knowledge scale had 14 items across 3 domains: general hypertension knowledge, lifestyle and medication management, and measurement and treatment goals. Scores were positively associated with education (0.28, P<.0001), print health literacy (0.21, P<.001), health numeracy (0.17, P<.001), and patient activation (0.12, P=.015) but no association was found with diastolic or systolic blood pressure. The HELM knowledge scores increased following the educational intervention from baseline (mean, 8.7; standard deviation, 2.2) to 12-month follow-up (mean, 9.2, standard deviation, 2.2; P<.001). We conclude that the HELM provides a valid measure of the knowledge required for patients to take an active role in the chronic disease management of hypertension.

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BACKGROUND: Research shows that community-based membership organizations are effective partners in health promotion activities; however, most community organizations do not participate in such partnerships. There is little research regarding the geographical and organizational characteristics associated with participation. OBJECTIVE: We examined the factors associated with community-based veterans service organization (VSO) units' decision to participate in a health promotion project. METHODS: We collected location and organizational characteristics regarding 218 VSO units asked to participate in POWER, a partnership to improve hypertension self-management skills between the Medical College of Wisconsin, the Milwaukee Veterans Affairs Medical Center (VAMC) and Wisconsin branches of the American Legion, Veterans of Foreign Wars (VFW), Vietnam Veterans of America, and National Association of Black Veterans. We tested the association of these characteristics with participation using chi-square and Fisher's exact tests for categorical variables, and analysis of variance and the Kruskal-Wallis test for continuous variables. We used multivariable logistic regression to identify factors independently associated with participation. RESULTS: In bivariable analyses, likelihood of participation was positively associated with increasing membership (p < .001), meeting attendance (p < .001), publication of an organizational newsletter (p < .001), presence of a women's auxiliary (p = .02), and location within 44 miles of the VAMC (p = .047). On multivariable analysis, only meeting attendance and census tract-level educational attainment predicted participation. CONCLUSIONS: Greater membership sizes, meeting attendance, and more group resources might be important factors for researchers to consider when initiating community-based health and wellness programs.

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OBJECTIVES: The purpose of this study was to determine the influence of program factors on participant engagement in POWER, a peer-led intervention designed to reduce hypertension, increase hypertension knowledge, and improve other relevant health behaviors, such as diet and exercise, among US veterans involved in veterans service organizations throughout Southeastern Wisconsin. METHODS: Two hundred and nineteen hypertensive members from 58 VSOs participated in a year-long peer-led intervention designed to improve hypertension knowledge, disease self-management behaviors, and health outcomes. This study represents a qualitative evaluation of post and participant engagement in this intervention. We triangulated data collected via three qualitative approaches (observations, focus groups, and in-depth interviews) from intervention posts to derive a model of engagement. RESULTS: Our findings indicate that discrete characteristics of the peer leaders, post members, posts, and the intervention itself contributed to intervention engagement. DISCUSSION: We make suggestions for future research studies, particularly as related to understanding how peer leader identities and cultural norms within VSOs might contribute to peer-led health intervention success.

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BACKGROUND: Although arthritis is disabling, highly prevalent, and often treated without health professional input, little is known about the treatments selected by affected individuals. Such information is important because of the toxicity associated with some arthritis treatments. OBJECTIVE: To describe the pattern of drug treatment use in a sample of persons with arthritis. METHOD: The authors distributed an 11-item survey to veterans attending veterans' organization post meetings in southeastern Wisconsin during November and December 2009. Of 32 posts, 26 (81%) returned surveys from 446 persons; survey count and attendance figures suggest that the majority of attendees completed surveys at participating posts. Most respondents were older (75% aged 60 years or older) men (90%). Respondents with arthritis reported whether they had used each of seven drug therapies in the past year. RESULTS: Almost all members of participating posts responded to the survey, increasing the likelihood that this was a representative sample. Most respondents (290 of 446, 65%) reported having arthritis, which impaired function in 78.6% of them. Most of those with arthritis (252 of 290, 86.9%) had used at least one drug treatment for arthritis in the last year. Acetaminophen use (41.0%) and use of an over-the-counter nonsteroidal anti-inflammatory drug (42.1%) were common. Nonsteroidal anti-inflammatory drug use did not decrease with older age or increase with greater functional impairment. CONCLUSIONS: Self-medication for arthritis is common and often does not follow clinical guidelines. Efforts to improve the quality of osteoarthritis care that focus solely on health care providers are unlikely to ensure optimal osteoarthritis care.

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Community organizations, such as churches, clubs, and senior centers, can be important locations for health programs. However, little is known about the organizational factors that influence participation and engagement in health programs. To learn more, we evaluated a community-based program designed to help US military veterans better manage their high blood pressure. The program involved training a pair of veterans to deliver health-related presentations at their local units. We found that factors such as larger meeting attendance size, rural location, age diversity, and member enthusiasm were positively associated with both a willingness to participate and a high level of engagement in program activities.

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Efforts to increase community members' involvement in research may create novel ethical challenges. We describe an ongoing randomized trial of a peer-delivered intervention to encourage hypertension self-management. Community members serving as peer leaders participate in subject recruitment, the informed consent process, and intervention. We describe our experience with several ethical issues that may arise when conducting research in similar settings: (1) coercion of community members, by the community, to participate either as leaders or as study subjects; (2) threats to the privacy of health information; and (3) conflict between peer leaders' roles as community members and study team members.

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BACKGROUND: Despite consensus that effective treatment of hypertension reduces morbidity and mortality, control rates remain relatively low. This report describes key features of a peer support program designed to motivate individuals to improve self-management of hypertension. METHODS: We recruited Veterans of Foreign Wars posts in southeastern Wisconsin and trained members of these posts to be peer health leaders over a period of 18 months. The curriculum covered information important to blood pressure control, as well as peer educator skills. During this time, the peer leaders presented educational materials and encouraged self-monitoring of blood pressure at post meetings. Surveys and focus groups were conducted to evaluate the adoption of the program at the posts. RESULTS: After a series of informational mailings and visits to veteran posts, 15 posts and 27 peer leaders volunteered to participate. Fourteen posts (93%) continued active participation throughout the study period, as did 24 peer leaders. Peer leaders reported that they gained health knowledge, skills, and confidence to perform as informational resources at their posts, resulting in greater levels of health support among post members. CONCLUSION: The partnership of health care professional, medical school, and veteran service organization successfully organized and maintained a community-based, peer-led program to promote healthy behaviors among Wisconsin's armed services veterans. Community physicians should be familiar with programs of this type as chronic disease self-management grows in appeal in our communities and increasing numbers of veterans return from armed service duty.

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BACKGROUND: The "Swiss cheese model" of systems accidents is commonly applied to patient safety, implying that many "holes" must align before an adverse event occurs. The Accreditation Council for Graduate Medical Education (ACGME) instituted work hour limitations to fill one such hole by reducing resident fatigue. OBJECTIVE: The objective of this study was to determine how residents perceive the impact of the ACGME rules and other factors on patient safety. DESIGN: The study was designed as a focus group study. PARTICIPANTS: Participating in the study were 28 internal medicine residents, of whom 13 were from a university-based program that includes both an academic medical center and a Veterans Affair (VA) hospital, 9 were from a community-based program, and 6 were from a freestanding medical college that includes a large private teaching hospital and a VA hospital. MEASUREMENT: Grounded theory analysis was used to examine transcripts of the focus group discussions. RESULTS: A model of contributors to patient care errors emerged including fatigue, inexperience, sign-outs, not knowing patients, "entropy" (which we defined as "overall chaos in the system"), and workload. Participants described the impact of both intended and unintended consequences of the work hour rules on patient care. Residents reported improved well-being and less fatigue, but had concern about the effect of reduced continuity on patient care. CONCLUSION: Our focus group participants perceived that the ACGME work hour limitations had minimized the impact of resident fatigue on patient care errors. Other contributors to errors remained and were often exacerbated by methods to maintain compliance with the rules.

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