LinkMedica-Heart is a novel Internet based program intended to support people who seek to improve their life style by means of changes in diet and physical activity. The program is currently under evaluation in a clinical study and the present study is a feasibility test of the LinkMedica-Heart Internet based program.The aim of this study was to evaluate LinkMedica-Heart, an Internet based program we designed for support and maintenance of patient-led life style changes.The feasibility study of LinkMedica-Heart presented here is a qualitative study. Nine general practitioners were invited to participate. Each practitioner was asked to introduce LinkMedica-Heart to not less than two patients, with a maximum of five patients per practitioner. Patients and general practitioners were both asked to participate in testing the program for a period of 6 months. At the end of 6 months, evaluation meetings were held with the general practitioners, and separate interviews took place with some of the participating patients who were selected by the GPs.Five general practitioners and 25 patients participated in the study. The general practitioners and the patients were enthusiastic about the prospect of an Internet based life style change program. However, the program was not able to sustain patient loyalty over an extended period. The doctors found that the program was much too complicated to navigate and that the results from the program could not be trusted. The patients in contrast had fewer complaints about the program design, but found that the advice given by the program was too elaborate and detailed and, in general, did not add to the patient's knowledge on life style change.Our study confirms that there is a need for, and a receptive attitude toward a Web-based program that supports people who want to improve their life style and health. LinkMedica-Heart in its present form does not satisfy these needs. We suggest a number of design changes and improvements to the program. Obesity and physical inactivity are major causes of a number of diseases. Several studies prove that a change of life style towards a healthy diet and ample physical activity reduces the risk of a large number of diseases ,2. HowevIndividual and group based education of individuals for implementing life style changes are seldom possible due to often-limited resources. There is an enormous need for innovative ways to introduce and maintain life style changes in people at risk from life style related diseases.The growth and extensive use of the World Wide Web presents a novel opportunity for mass communication and patient education . Taking advantage of the new medium, the Research Centre for Prevention and Health (RCP), Glostrup, Denmark, in cooperation with AstraZeneca (AZ), Denmark, created a novel Internet-based program called LinkMedica-Heart (LMH), for support and maintenance of life style changes in people at risk from life style related diseases. The program's effect on predictors of life style related diseases is currently under investigation in a clinical trial that compares changes in serum cholesterol in patients using the LMH program, with those of patients using a ‘placebo' program. We plan further studies on other predictors of life style related diseases that may be prevented with the LMH program.The present study was originally intended to be a pilot test with a small number of general practitioners (GPs) testing the web pages, together with some of the practitioners' patients, in order to help us identify and correct errors in the program prior to beginning the actual clinical study mentioned above. The feedback we got from the GPs and some of the patients during the pilot study could be of interest for other researchers working on Internet-based patient education. Hence, we decided to expand the pilot study with some in-depth interviews with selected patients and present our findings on the feasibility of LinkMedica-Heart as an Internet-based program for support and maintenance of life style changes.The aim of LinkMedica-Heart is to provide support and information for people trying to achieve a healthy life style through focus on diet and physical exercise. LMH is part of a closed Web site that is currently accessible only by people who participate in the study.To use LMH, the patient must register and chose a username and a password. The patient is then required to enter his or her sex, height, weight, and E-mail address. A screenshot of LMH's home page is shown in                     After registration, the user is asked to activate a life style change program. To do this, the patient must first fill-in two questionnaires: one about diet, and the other about physical activity  number. One ME corresponds to a person's energy expenditure when sitting relaxed. The ME of an activity times the patient's weight, the minutes spent per day on the particular activity, and a constant for the patient's sex, gives the amount of energy spent on the particular activity, per day. The total energy spent per day is a sum of energy spent on all activities in a day. The activity questionnaire takes only a few minutes to fill-in.After filling-in both the diet and activity level questionnaire, the patient is presented with results that summarize energy intake, energy expenditure, and composition of diet with regard to protein, carbohydrate, fat, alcohol and fibre per day .The patient is then asked to select one of five offered diet programs, and one of three activity programs. The patient can select a program based on how motivated the patient is for a life style change: a highly motivated patient might select an intensive program, while a less motivated patient may select a program that aims at creating the needed motivation.After the patient has activated a program, he or she receives a computer-generated E-mail with results of the questionnaire and personalized advice on how to improve life style through changes in diet and physical activity. The activity questionnaire, the advice generator, and textual content were created by RCP.After 4 weeks, patients received an E-mail asking them to update answers to the diet and physical activity questionnaires. When updating their answers, patients were only required to enter changes in diet or physical activity since the last questionnaire. This made updating much less demanding than the first entry. Again, the patient received results and advice based on the current life style change program. The patient could at any time change their program to a more or less intensive one. The content of E-mail advice changed according to the newly recommended program. Thus, the overall goal of the program was to introduce and maintain permanent changes in life style, rather than a radical short-term change in diet.A single life style change program ran for 6 months. If the patient chose a different program in between, the new program would then take over for the next 6 months.                    Nine GPs, selected by two AstraZeneca sales representatives, were invited to participate in the feasibility test of LMH. Each GP was asked to introduce between two to five patients to the LMH program. During the feasibility test, the GPs were asked to see each patient at least once after 3 to 6 months after the patient was introduced to the program. After 6 months, we held an evaluation meeting with the GPs. At this meeting, the GPs gave an oral summary of their own and their patients' experience with LMH. Two persons prepared separate minutes of these meetings.We further asked two of the GPs to select a total of four patients who had participated in the feasibility test to participate in semi-structured in-depth interviews. We chose to interview patients as a qualitative research method, since the feasibility of the program could not be quantified or analysed by statistical methods. Qualitative research focuses on people's lives, their experiences, and emotions, as well as cultural phenomena and social movements .One of the methods used in qualitative research is the semi-structured interview, the main source of empirical material in this study. According to Kvale, the purpose of the qualitative research interview is to describe and interpret themes in the patients' lifestyle that shape a continuum between description and interpretation .In this study, the main research questions for which we sought answers in the patient interviews were: (a) how do patients use the lifestyle program, and (b) what do they learn about lifestyle when interacting with the program. To answer these questions, we made an interview guide which outlines three main themes for the patient interview sessions: the patients' (a) extent of involvement in the pilot study, (b) use of the LMH lifestyle change program, and (c) extent of putting into practice advice given by the program.                    Interviews were held by the second author in the patients' homes to help make them feel comfortable during the interview sessions. In addition, a student of psychology was present as an observer.The interviews lasted between 45 and 60 minutes and were recorded on Minidisks. Immediately after each interview, the interviewer and the observer discussed their interpretations of the interview, and the patient's attitude towards the program. Later, the interviewer alone revised the interview recordings three times: the first was a general recall of the interview without a specific focus; the second time, the interviews were divided into sections by means of the Minidisk player's bookmark function. Each interview had at least 30 to 40 sections. From each section, significant words and statements were noted and used in the third revision to organize each interview into thematic units.We also received some unsolicited E-mails and telephone calls from patients who participated in the study, conveying their experience with the program. In addition, one GP asked his patients to fill-in a questionnaire regarding four aspects about LMH: usability, reliability, suggestions for improvement, and relevance of the program for lifestyle change.The minutes of the interviews, together with the E-mails, questionnaires and calls from patients comprise the data material of this study.Three GPs withdrew from the pilot test, one because of illness, and two because of time constraints. One GP was unable to get any patients signed up for the study due to technical problems with his Internet connection. Another GP could not participate in the evaluation meeting after the pilot test and sent his comments by E-mail. Four patients were interviewed for the qualitative research interview. Additionally, we received two unsolicited E-mails from two participating patients, and four anonymous filled-in questionnaires turned-in by patients of the GP who could not attend the evaluation meeting.Four topics came-up during discussions at the evaluation meeting:Program errorsInitial perception of the program conceptProgram usabilityProgram design.Early on during patient inclusion in the feasibility test, we discovered that the E-mail service did not work, and advice and reminder E-mails were not mailed to patients. This error affected about half the patients for a month and a half, and clearly gave them the impression that the program was ‘dead'.A small number of minor errors, primarily in algorithms controlling advice messages were also found and corrected.Before they were introduced to the LMH program, the GPs, their nurses, and patients were enthusiastic about the idea of having a life style program available on the Internet. The GPs agreed that general practice needs new means to help introduce and maintain life style changes for patients at risk of life style related diseases. One GP (GP2) said, “The patients were happy when I asked them to participate in a test of a life style program. When I introduced the program to them, their eyes shined and they were ready to start immediately.”An anonymous letter from a patient noted, “Unfortunately, I never got into the program, but I wanted to do it very much. I believe I would have benefited from it.”short-term                        diet program, rather than a program intended for long-term permanent changes in life style. For example, a middle-aged female expressing her expectations in an E-mail said: “It would have been great if you had to enter your diet every day instead of only once a month. This is important when you have to lose weight. In this way you get the feedback immediately and can correct your mistakes the day after.” We were surprised by this error in perception, since we had worked very hard to communicate LMH as a lifestyle change program rather than a diet reduction program during initial meetings with GPs and on the LMH Web site.However, during the feasibility test it became obvious from informal contacts (telephone conversations and E-mails) that most patients perceived the program as a As expected, the GPs had different opinions regarding the LMH Web site layout: one GP found the site layout elegant; another GP found it boring with tiny fonts and too few graphics; and the other three GPs had no special opinion for or against the layout.All GPs, however, agreed that the program was much too complicated to navigate. GP3 said, “The program is complicated, and navigation is confusing. It is difficult to navigate the site.” GP2 stated, “When a patient logs on for the first time, the program should be extremely simple with the possibility of adding more and more functionality as the patient gains experience.”Interestingly, some patients did not agree with the GPs negative perception of the site's usability. The same patient who expressed her perception of the program as a diet-reduction program wrote in her E-mail, “First I want to say that the site is logically built, easy to navigate and has some very good information.”The term ‘program design' refers to the logical design of the LMH program—from the patient when first filling-in the questionnaires, viewing the results, then choosing a life style change program in keeping with the extent of personal motivation, and finally, receiving regular advice by E-mail.The GPs agreed that the questionnaires, especially the diet questionnaire, were far too long. GP3 said, “The questionnaires are too long, and the patients lost interest very quickly.” The GPs also had doubts about the reliability of the results. As GP1 said, “The patients did not trust the results.” This view was supported by GP2 who tried the program himself and found that the results did not match his own observations on the balance between his energy intake and expenditure.In general, there were surprisingly few comments on advice given via E-mail. This, of course, was partly due to the program error that withheld E-mails to patients for a month and a half. However, the advice was also available on-line on the LMH Web site and the patients did not seem to pay much attention to the available advice. GP3 told us, “Most patients said that they had not seen the advice content and if they had, they did not trust them because they were in conflict with their personal experience.”An important observation from the study is that none of the patients completed their life style change program. Personal questionnaires were updated no more than a few times, if ever. The patients did not give any clear explanation why they lost interest in the program. They simply disclosed that they stopped using the program. In an anonymous questionnaire a patient wrote: “To be honest, I have not entered the site more than once.”The GPs, too, agreed that the program was unable to sustain the patient's attention for more than a short period. GP3 said, “… when using the program, they lost interest quickly.” GP2 summed up, “At the beginning, the patients were highly motivated. But the program is much too complicated.” In the GPs opinion, one reason for the patients' loss of interest was that the program's interaction with the patients was too infrequent and meagre. As GP1 said, “It is crucial to have frequent contact with the patients, especially in the beginning.”From the analysis of patient interviews, four issues emerged:LMH did not provide patients with new informationThe feedback E-mail content was too detailed and elaborateChanges in life style do not come from using a computer based program aloneHuman support and contact are important if life style change programs are to succeed.Although the content of advice based on the results from the questionnaires is highly detailed, the patients interviewed did not find that they were given any new information. This point became clear early in the interview sessions, as we noticed that the patients' knowledge of lifestyle and their general awareness of how to eat, drink, and exercise to stay healthy was high from the beginning. Consequently, the patients quickly lost interest the program since they felt that they already knew the outcome. Hence, the program was not able to establish a personal interaction with the patients. One of the patients, patient C, said, “I have loads of materials about healthy living. I don't need any more.” From the patients' viewpoint, the information on LMH is very basic and could be one of the reasons why the patients lost interest in the program. Patient A said in the beginning of the interview, “I have been on a diet since I was 11 years old, so I know a lot about what is healthy and what is not.” When another patient, patient D, was asked about his opinion of the program, his comment was, “I don't need the program to tell me that I eat less than I expend. I can see that on the scale – can't I?”Regarding the texts being too broad and elaborate, patient D said that he spent too much time locating information on the LMH Web site and that he would rather call his doctor or nurse to get a quick answer. Another patient, patient B, preferred to have all information in print and said: “I spent 50 minutes printing everything, and I didn't even want to read it … it's too much. There is nothing wrong with the content, but it's too much.”As for the third issue , all patients agreed that the use of the program did not provide the necessary support in their struggle towards a healthy life style. They said that the program itself was merely a tool and that it could never replace support from a health care professional. One of the patients, patient C, noted that the computer could not keep an eye on her, as her nurse could, “I need another person to check my weight and say, ‘it's for your own good, it's not for me you are doing this.' The program may give me advice and ideas, but I need the nurse to coach me.”Patients seemed to give a high value to personal relations with a health care professional. They expressed great conviction in the competence of the health care professionals, a trust that they could not seem to establish with the LMH computer based program. Hence, the patients were sceptical with the results that the LMH program provided. Patient A said, “… it's the doctor who is educated and knows things. You cannot expect a computer program to know what is good for you. However, if your doctor tells you to use a computer program, it might provide extra information.” As a result, patient A acknowledges that when the doctor endorses a program it must be of some value for her as a patient.As stated in the introduction, this study was intended merely to be a test of the LMH program and to find software errors in the program. Data for the study was collected rather randomly from different sources: minutes from evaluation meetings with hand-picked GPs who reported their patients' experience with the LMH program; unsolicited E-mails and letters from patients; and issues appearing in interviews with selected patients. We acknowledge that the patients who where selected by the GPs to participate in the study, especially the patients selected for interviews, may not at all be a representative sample of the general population of people (not necessarily patients), needing life style changes. However, we believe that despite these limitations, our findings and conclusions may be of interest to other researchers working on internet based disease management or prevention.Our pilot study confirms the need for, and an open attitude towards life style change programs delivered via the Internet. The doctors confirm the need to aid their patients starting a life style change program with a tool that complements the doctor's advice and direction. The patients, too, seem to be eager to get additional help and support in striving towards a healthy life. The Internet appears to be an ideal medium for providing the additional support that complements the doctor's counsel.However, the present version of LinkMedica Heart does not seem to fulfil this need: the patients did not use the program more than a single, or a few times.It is important to stress that the study was a real time study, with an aim to learn how GPs and their patients use and perceive LMH—after a relatively short interaction with the program. The objective was not to investigate the effect of the LMH program on patients using the program. Hence, we did not attempt to control either the GPs' or the patients' use of LMH during the test phase.Our study identifies three issues that need to be addressed in order for the LMH program to be successful in bringing about patient lifestyle changes:Complicated user interface and navigationReliability of questionnaire results and content of adviceLack of personal interaction between the program and the patient.It is tempting to think that if the user interface and navigation were improved, it would be sufficient to sustain the patients' attention. Without any doubt, an improved interface would certainly help encourage new patients to enter the program for the first time—especially if they are attempting to join the program on their own without support from a healthcare professional. However, improvements to the interface may not necessarily sustain participant loyalty to the program for an extended period. The patients included in the study were handpicked by their GPs and were cautioned that they were testing a new program with many rough edges. In addition, the patients in the study had support of their GP's to help them get started with the program. Hence, we do not believe that simply improving the user interface would be enough for LMH to be a successful Internet based program.higher than expenditure, when in fact they had been loosing weight. Some other patients were told that their intake was lower than their expenditure when in fact they were gaining weight. Moreover, patients were not inclined to read the lengthy textual content, either on the computer screen or as a print out of the text.A lot of effort was put into creating the content and the logic behind the result and advice text for the LMH Web site. To make the results and advice precise and personal, a typical feedback message from LMH was almost as long as five printed pages. Nevertheless, some patients felt that the feedback was not in accordance with their own expectations. For example, the LMH program told some patients that their energy intake was The accuracy of the energy calculations in the LMH program was not an issue in this study. However, accuracy of the calculations would be an issue and a major problem if patients were wary of the program overall. Any mistrust will inevitably lead the patients to stop using the program, even if it is the patient who is mistaken and not the program.It might be a better idea to simplify the feedback function of the program engine with precise, qualitative advice in the form of concise messages based on a patient's own perception of his or her dietary habits, coupled with measured developments in weight and waist circumference. The questionnaires could also be similarly simplified.The observation that patients are more likely to trust their own opinion than that of a computer program supports our previous findings from a similar Web service for asthma patients, LinkMedica-Asthma . In the The diet questionnaire is intended to reveal the diet for the previous month. Therefore, it would be misleading to ask the patient to update the questionnaire more often. On the other hand, the study shows that in order to sustain patient attention, the program needs to interact with patient more frequently, preferably on a daily basis. Some patients wanted to enter their questionnaires every day, while others preferred a less demanding program. Consequently, the ideal program should be adaptable to the patient's preference. Combining succinct, qualitative questionnaires with concise advice delivered via E-mail, and/or SMS (Short Message Service provided by wireless phone companies), could prove useful. Also, breaking up advice messages into small fragments, delivered on a daily basis might help patients who do not want to read long, all-inclusive texts.In summary, we suggest a number of improvements to the LMH Web site:qualitative evaluation of the patient's dietary habits.A simplified diet questionnaire for a Frequent (preferably daily), and concise feedback messages from the program to the patient in the form of E-mail and/or SMS messages. These messages can possibly contain practical advice about healthy living, and food recipes attuned to the patient's lifestyle profile.Suggestions to monitor weight and waist circumference. Physical measures of weight and waist circumference can be the patient's means of assessing whether there is any positive effect of his or her lifestyle change efforts.Removal of options in choosing a lifestyle change program. The LMH program in its current state prompts the patient to chose between several lifestyle change programs based on his or her degree of motivation. Our study suggests that patients are highly motivated from the beginning and that too many program options confuse them. Hence, the program should automatically select the most appropriate lifestyle change program based on the patient's profile.This study confirms the need for, and a positive attitude towards Web-based programs for supporting people who want to improve their health through life style changes. In its present form, LinkMedica-Heart, our life style change program, does not address these needs. A number of design changes and improvements to the program are suggested.


Published research on the use of Web-based behavior change programs is growing rapidly. One of the observations characterized as problematic in these studies is that participants often make relatively few website visits and spend only a brief time accessing the program. Properly structured websites permit the unobtrusive measurement of the ways in which participants access (are exposed to) program content. Research on participant exposure to Web-based programs is not merely of interest to technologists, but represents an important opportunity to better understand the broader theme of program engagement and to guide the development of more effective interventions.The current paper seeks to provide working definitions and describe initial patterns of various measures of participant exposure to ChewFree.com, a large randomized controlled trial of a Web-based program for smokeless tobacco cessation.We examined measures of participant exposure to either an Enhanced condition Web-based program  or a Basic condition control website . Specific measures focused on email prompting, participant visits , and Web page viewing .Participants in the ChewFree.com Enhanced condition made more visits and spent more time accessing their assigned website than did participants assigned to the Basic condition website. In addition, exposure data demonstrated that Basic condition users thoroughly accessed program content, indicating that the condition provided a meaningful, face-valid control to the Enhanced condition.We recommend that researchers conducting evaluations of Web-based interventions consider the collection and analysis of exposure measures in the broader context of program engagement in order to assess whether participants obtain sufficient exposure to relevant program content. One of the common findings of research on Web-based behavior change programs is that participants spend only a relatively meager amount of time accessing their online intervention . This imThis paper describes participant exposure to a two-arm randomized controlled trial of Web-based programs designed to assist adults in quitting smokeless tobacco (either snuff or chewing tobacco). Following a brief program description, we present a set of unobtrusive measures of website exposure  and the We designed the ChewFree trial to compare the efficacy of two smokeless tobacco cessation websites: Basic and Enhanced.The Basic condition, which represented a subset of the content presented in the Enhanced condition, offered a printable self-help smokeless tobacco cessation booklet, printable cessation resources , and annotated links to other recommended websites for tobacco cessation. The Enhanced condition offered a tailored and interactive Web-based program that included text-based information , video-based testimonials, printable resources, interactive activities, annotated links to other website resources, and two Web forums .ChewFree.com intervention components were based largely on Bandura's Social Cognitive Theory -17 in whEnough Snuff—an adaptation of the smokeless tobacco cessation manual used in prior research  to explore whether smokeless tobacco cessation might be related to message types, whether cessation and maintenance strategies shared in postings are consistent with program recommendations, and the extent to which postings convey differing levels of confidence and self-efficacy across participants as well as within participants over time.information scents in website materials. This model suggests that websites should foreshadow content even when it is not immediately accessible in order to engage users. It also points to particular usage patterns—brief initial visits followed by later visits of more duration [There is a significant risk of collecting so much detailed exposure and engagement data that the task of analyzing and interpreting results becomes difficult. We suggest that this task can become more manageable and, thus, more fruitful, by focusing its scope through the use of a rationale that incorporates both theory and pragmatism. Potentially relevant rationales are not difficult to identify. Consider, for example, a rationale that builds on the Web foraging model ,50, whicduration . The Traduration  suggest duration ,52,53, wWe view exposure as representing one of a set of complementary measures of the broader theme of program engagement. Other engagement measures include participant comprehension of program content, practice of that content , self-reported satisfaction with the function and content of the website, and measures of self-efficacy. While exposure is obviously important , it represents only one piece of the puzzle in seeking to understand program effectiveness.


Online computer-tailored smoking cessation programs have not yet been compared directly.To compare the efficacy of two Internet-based, computer-tailored smoking cessation programs.Randomized controlled trial conducted in 2003-2004. Visitors to a smoking cessation website were randomly assigned to either an original online, interactive smoking cessation program or to a modified program. Both programs consisted of tailored, personalized counseling letters based on participants' characteristics, followed by monthly email reminders. The original program was based on psychological and addiction theory, and on preliminary research conducted in the same population. The modified program was shorter and contained more information on nicotine replacement therapy and nicotine dependence, and less information on health risks and coping strategies. In both programs, 1 month and 2 months after entering the study, participants were invited by email to answer the same tailoring questionnaire again in order to receive a second counseling letter. Participants in both programs obtained, on average, 1.2 feedback counseling letters over 2.5 months, and 84% received only 1 feedback letter. The outcome was self-reported smoking abstinence (no puff of tobacco in the previous 7 days), assessed 2.5 months after entry in the program. We report results from intention-to-treat (ITT) analyses, where all non-respondents at follow-up were counted as smokers.P=.003) in the original and modified programs, and 25.2% and 15.7%  in baseline former smokers. While we found statistically significant differences in quit rates in smokers in the contemplation stage favoring the original program , no between-group differences in quit rates were observed in smokers in the precontemplation  and preparation  stages of change.The baseline questionnaire was answered by a total of 11969 current (74%) and former (26%) smokers, and the follow-up survey by 4237 people (35%). In an ITT analysis, abstinence rates in baseline current smokers were respectively 10.9% and 8.9% (odds ratio [OR]=1.24, 95% confidence interval [CI]1.08-1.43, In smokers in the contemplation stage of change and in former smokers, the original program produced higher smoking abstinence rates than the modified program. Self-help smoking cessation booklets and leaflets can reach large numbers of smokers, but they may not be very effective . ComputeP<.001) in the intervention group than in a control group that received no treatment. The same program is also available online, but the efficacy of the online version is unknown. We compared the online version of this program with another online smoking cessation program intended for users of nicotine replacement products.In a previous study, we tested a paper version of a computer-tailored program ,11. In tSeveral websites offer interactive, computer-tailored smoking cessation programs, but these programs have never been compared directly in a randomized trial. Our aim was to compare the efficacy of two online, computer-tailored smoking cessation programs.arrêter de fumer, fumer, or tabac  .Participants were visitors of Stop-tabac.ch, a French-language website that provides information, advice, and support to smokers and ex-smokers. This website was listed among the 5 best websites on smoking cessation in a recent study , and it Various services are available to visitors of Stop-tabac.ch, including fact sheets, booklets, answers to frequently asked questions, personal stories written by current and former smokers, discussion forums and chat rooms, tests, games, and two interactive, computer-tailored smoking cessation programs ,11. EachBoth programs consisted of tailored personal counseling letters compiled by a computer according to the answers made by participants. The counseling letters appeared on the screen immediately (<5 seconds) after the answers were submitted. Participants were advised to print their counseling letter and to read it again later. Participants in the original program were also advised to print stage-matched booklets available on the website.precontemplation, no intention of quitting smoking in the next 6 months; contemplation, seriously considering quitting in the next 6 months; preparation, has decided to quit in the next 30 days; action, has quit smoking for 6 months or less; and maintenance, has quit smoking for more than 6 months)[The original program was based on the Transtheoretical Model of Change ,15, on t6 months),23,24,256 months). The int6 months),11.                                        The modified program was developed by us for Novartis, a producer of nicotine replacement products, when these products became available over-the-counter  in Switzerland in 2000. This program was intended to provide some smoking cessation counseling to smokers who bought OTC NRT products and thus did not receive medical supervision. Compared with the original program, the modified program used a shorter questionnaire (38 questions) that included ad hoc questions instead of validated multi-item scales . The cou                                        In both programs, 1 month and 2 months after entering the study, participants were invited by email to answer the same tailoring questionnaire again in order to receive a second counseling letter. To write the second letter, the computer compared each participant's new answers with the answers given on their previous visit. Participants were congratulated for any progress they had made since their last visit or encouraged, if they had relapsed. In both groups, participants received on average 1.2 counseling letters; 84% of participants received only 1 counseling letter and 16% 2 or more letters.Yes or No directly in the email message: "Did you smoke any tobacco in the past 7 days ?" The criterion of 7 days' abstinence was used in a recent guideline to assess smoking cessation in randomized trials [To assess smoking abstinence, an email message was sent out 11 weeks after receipt of the baseline questionnaire; those who failed to respond received up to 3 email reminders. Participants answered the following question by clicking on d trials . We usedSample size calculations indicated that a sample of 5300 was necessary to detect a between-program difference of 2 percentage points in abstinence rates in current smokers . The expected difference of 2 percentage points was estimated on a basis of a synthesis of previous studies of computer-tailored programs , and takt tests to compare means. We used odds ratios (OR's) with 95% confidence intervals (CI's) to express the proportion of non-smokers (abstinence rate) in the original program compared to the proportion of non-smokers in the modified program. We tested the effectiveness of the program in subgroups, stratifying by age, sex, number of cigarettes per day, and stage of change.We used chi-square tests to compare proportions (eg. abstinence rates) and Because participation rates in the follow-up survey differed in the two groups, we report both intention-to-treat data, where all baseline participants were included in the denominator and non-respondents were counted as smokers, and an analysis including only those who took part in the follow-up survey. We also conducted a sensitivity analysis, extrapolating results under a hypothetical situation where response rates to the follow-up survey were assumed to be the same in the two study arms.The raw database included 12434 records. We excluded 245 participants who had taken part in both programs and deleted 220 entries of people registered twice in the same program. Thus 11969 participants were included in the study.                     At baseline, the two study groups were similar in terms of age and sex distributions, smoking status (current or former smokers), stage of change, cigarette consumption, and, among former smokers, the number of days since smoking cessation . As in a2=76.7, P<.001). In both groups, the median interval between the baseline and follow-up surveys was 2.5 months .The response rate to the follow-up survey was 35.4% (4237 of 11969). However, more participants in the original program  than in the modified program  answered the follow-up survey  (P=.003) and in baseline former smokers .At follow-up, when all baseline participants were included in the denominator and non-respondents were counted as smokers, the 7-day abstinence rate was higher for the original program than for the modified program  . Thus coAmong smokers in the precontemplation and preparation stages of change, there was no statistically significant difference in quit rates between programs; but the original program produced more quitters than the modified program among smokers in the contemplation stage . Among l2=5.0, P=.03) higher in the original program  than in the modified program .When we included only the 4237 participants who answered the follow-up survey, abstinence rates were significantly . Thus the original program was still more effective than the modified program, even after taking into account the difference between groups in response rates.In a sensitivity analysis, we extrapolated data assuming a hypothetical situation where the same proportion of participants in both groups (39.2%) answered the follow-up survey. Under this assumption, 2356 out of 6003 (39.2%) participants in the modified program (instead of 1896) would have answered the follow-up survey, and 800 out of 2356 (34.0%) would have quit smoking. Under this assumption, and including all baseline participants in the denominator, 13.3% (800 out of 6003) would have been abstinent in the modified program versus 14.6% (873 out of 5966) in the original program , the original program was more effective than no intervention ,11. ThisBecause the present study did not include a no-treatment control group, we are unable to say whether both programs were more effective than no intervention. However, quit rates in smokers in the modified program (8.9%) were higher than quit rates in smokers in the no-treatment control group in our previous study (3.3%) , which sThe follow-up in both programs consisted of short, monthly email messages inviting participants to answer the same questionnaire again, in order to receive a second counseling letter that was largely similar to the first one. This follow-up procedure may not have been intensive enough, which may explain why so few participants obtained additional counseling letters. The follow-up in the program could be improved by using individually tailored email messages, sent more frequently just before and after the quit date, as was done by Lenert and colleagues .The total cost of implementing the website where the two programs are available is currently 70000 Swiss francs a year (US$ 60000), for a reach of over 8000 participants per year in the computer-tailored programs, and for 600000 visitors per year to the website . The average duration of a visit to the website is 7 minutes, with an average of 8 pages viewed per visit. This is comparable to the cost of running a small smoking cessation clinic which would treat about 50 smokers a month.A strength of this study is that it was powered to detect small differences in quit rates in subgroups of participants . The response rate at follow-up was low (35%), but it was close to the average response rate of 39.6% reported in a meta-analysis of 68 Internet-based surveys , and it There were more non-respondents in the modified program group than in the original program. This could produce an artificial advantage for the original program in intention-to-treat analyses where non-respondents are counted as smokers. However, even when data were analyzed in respondents only, quit rates were higher in the original program. In addition, a sensitivity analysis showed that if participation rates had been similar in both study arms, the original program would still have been more effective than the modified program. Under this assumption however, the between-group difference would have been smaller.Fewer participants in the modified program than in the original program took part in the follow-up. The modified program was developed in collaboration with a pharmaceutical company and emphasized NRT use. Participants were informed of this collaboration and may have been less keen to take part in the follow-up of a program associated with the industry than in the original program, which was university based.Because the study did not include a no-treatment control group, it remains possible that the natural quit rates in this sample  lies somewhere between the quit rates measured in the 2 study arms. In this case, the programs would have no effect. However, the original program produced similar quit rates whether it was implemented on the Internet or on paper, and these quit rates were higher that in the no-treatment control group in our previous study . This suThe difference in program efficacy between the original and modified versions was observed only in smokers in the contemplation stage of change, but not in those in the precontemplation and preparation stages. Similarly, the paper version of the original program had no effect in smokers in the preparation stage . The papWe measured point prevalence of abstinence after 2.5 months, but this approach may not reflect long-term continuous abstinence rates. In our previous study of the paper version of the original program, we showed that the effect measured 7 months after entry into the program was not maintained, one-and-a-half years after the intervention was stopped . PreviouWe conducted no biochemical verification of smoking status for several reasons. First, collecting saliva samples for the determination of cotinine (a metabolite of nicotine) or collecting expired carbon monoxide would have decreased participation rates . Second,The original program was more effective than a modified version of the same program intended for NRT users. Given the already documented large variability in the effect of computer-tailored programs , other a


Diabetes prevalence has reached epidemic proportions. Diabetes self-management education (DSME) has been shown to improve preventive care practices and clinical outcomes. In this study, we discuss the barriers faced during the implementation of DSME programs in medically underserved rural areas of Arkansas.Arkansas is a rural state, with most southeastern counties experiencing a shortage of health care professionals. The Arkansas Diabetes Prevention and Control Program and its partners established 12 DSME programs in underserved counties with a high prevalence of diabetes.DSME programs were delivered by a registered nurse and a dietitian who provided 10 to 13 hours of education to each program participant. Baseline, 6-month, and year-end data were collected on preventive care practices, such as daily blood glucose monitoring, foot examination, systolic and diastolic blood pressure, and glycosylated hemoglobin level, among the participants in newly established DSME programs.Of the 12 DSME programs established, 11 received American Diabetes Association recognition. The number of participants in the DSME programs increased 138% in 1 year, from 308 in February 2003 to 734 in March 2004. Preventive care practices improved: daily blood glucose monitoring increased from 56% to 67% of participants, and daily foot examinations increased from 63% to 84% of participants. Glycosylated hemoglobin decreased by an average of 0.5 units per participant who completed the program. However, many anticipated and a few unanticipated barriers during the implementation of the program could not be overcome because of the lack of an evaluation plan.Although results point to potential benefits of preventive care practices among DSME participants, interpretation of findings was limited by sample size. Sample size limitations are traced to barriers to assessing program outcome. Program evaluation should be integrated into the planning phase to ensure adequate measures of program effectiveness. Diabetes prevalence has reached epidemic proportions in the United States. In 2002, 18 million people were estimated to have diabetes (A systematic review of published studies addressing the effectiveness of population-based diabetes-related interventions recommends diabetes self-management education (DSME) . DSME emAlthough few studies have examined the challenges and barriers associated with establishing DSME programs in underserved areas ,7, issueArkansas is a rural state, with most counties in southeast Arkansas designated by the Health Services and Resources Administration as areas with a shortage of health professionals. Diabetes prevalence in Arkansas has been higher than the national average for the past decade, with 7.9% of Arkansans aged 18 years and older diagnosed with diabetes in 2002 . Costs fDSME reduces diabetes complications as well as associated costs . In 2001Healthy People 2010 target to provide diabetes education to 60% of people in the state diagnosed with diabetes (The Arkansas Diabetes Prevention and Control Program (ADPCP) assembled a coalition of public and private partners to establish DSME programs in counties with a high prevalence of diabetes. Particular attention was paid to counties with no DSME programs. The ADPCP used this opportunity to help Arkansas reach the diabetes . The ADPIn fall 2001, the ADPCP formed a coalition consisting of public entities including the Department of Human Services, the Arkansas Foundation for Medical Care, Health Information Design, the American Diabetes Association (ADA), and the Arkansas Minority Health Commission. The coalition also included private entities . The coalition's goal was to establish 12 high-quality DSME programs in underserved rural areas with a disproportionately high prevalence of diabetes. Objectives included identifying and recruiting hospitals and clinics interested in establishing DSME programs by February 2003, assisting with the resources required to establish DSME programs, assisting the DSME programs in obtaining ADA recognition by June 2003, assisting program instructors to become certified diabetes educators, and assessing program effectiveness at the end of 1 year of recruitment of all DSME programs. The coalition members identified their roles and responsibilities and worked together in making decisions for recruiting clinics, providing assistance with resources, and evaluating the intervention.The coalition identified underserved areas across the state as potential sites for DSME programs and assessed the existing infrastructure in those areas. Three certified diabetes educators were hired to assist with site recruitment and program implementation. Key hospital or clinic staff members  in underserved areas were contacted by telephone to assess their interest in establishing the DSME program. Coalition members and diabetes educators then conducted a 1-day visit with key personnel at each site expressing interest. They discussed the benefits of DSME, resources that could be provided to establish a program, details of the ADA-recognition application process, and reimbursement benefits of ADA recognition. The coalition provided sample educational tools and additional information through follow-up telephone calls. Based on these solicitations, the first 12 clinics that expressed interest were recruited to establish a DSME program. The clinics signed a memorandum of agreement for their roles and responsibilities, which included patient enrollment, patient education (DSME), and data collection, in return for the resources made available to them by the coalition. The recruitment phase began in January 2002, and 12 DSME programs were established by February 2003. DSME programs identified and enrolled people with diabetes through local physicians, pharmacies, and grocery stores.Life with Diabetes); a copy of Core Curriculum for Diabetes Education . The average HbA1c value for participants who completed the DSME program decreased from 8.15 at baseline to 7.65 at year end, a decrease of 0.5 units.Of the 319 participants due for the 1-year visit, only 20% (65) completed the 13 hours of diabetes education. Data were collected for 43 of these 65 participants on daily blood glucose monitoring, daily foot examination, and systolic and diastolic blood pressure. HbA1c level was obtained for 27 participants. There was some evidence of improvement in daily blood glucose monitoring, daily foot examination, systolic and diastolic blood pressure, and HbA1c levels . These cBarriers to program implementation were frequently identified through informal discussions among coalition members and DSME program staff. Patient-level barriers were identified and reported to the coalition by the DSME program staff. The coalition held a monthly teleconference with the DSME program staff to discuss progress and barriers experienced at both program and patient levels. During these calls, approaches to overcoming some of the barriers were proposed. The coalition members worked on applying solutions to the program implementation barriers. DSME program staff members worked to address patient-level barriers within their own clinics. There were anticipated and unanticipated barriers to implementation at both the patient and program levels. Anticipated barriersAt the program level, anticipated barriers centered on staffing and reimbursement for DSME. To obtain ADA recognition, the program needed at least one registered nurse and one registered dietician. Arkansas is a predominantly rural state, and more than half (58%) of its population lives in areas having a shortage of health professionals. Recruiting health professionals, particularly registered dietitians, was a challenge. Some DSME programs shared a registered dietitian to fulfill the ADA requirement.Reimbursement constraints took a number of forms. Insurance reimbursement only took place after ADA recognition of a DSME program, which did not occur until 6 months into the program. Although the coalition was not able to provide financial assistance during this period, the resources provided to DSME programs helped to overcome this barrier. A related barrier was that although there was no formal pre-existing DSME program in the participating counties, most counties included diabetes education as a subcomponent of their broader health care services. Rural health centers were not always reimbursed because diabetes education was considered a service already available. These rural health centers perceived the DSME program as contributing beyond their current services, so they applied for grants to cover program costs. This was one approach used by DSME programs to secure additional funds.Anticipated patient-level barriers included transportation, literacy, and reimbursement. Patients with no means of transportation needed to travel long distances to reach a DSME program site. To address this barrier, some DSME programs provided transportation by hospital vehicles; others coordinated transportation through local churches. Some patients had very little formal education, which presented a substantial barrier to understanding key DSME messages. In response, program staff members assisted patients by reading the materials to them. Medicaid members were not reimbursed for diabetes education. This barrier was anticipated, but the coalition was not able to overcome it. Because Medicaid members were asked to pay for DSME at their own expense, many dropped out of the program.Unanticipated barriersUnanticipated barriers included a lack of consistent data collection processes among DSME sites and participant retention. DSME programs were asked to enter participant information into the data collection system regularly, but this was not consistently done. Some program staff members said they lacked the resources (people or time) for data entry. Because the coalition could not assist with data entry and staff members did not understand the significance of gaps in data collection, the problem remained unsolved. Motivation to collect data was further decreased once sites received ADA recognition.Participant retention posed a challenge partly as a result of environmental factors associated with rural health settings. The coalition's intent was to establish DSME programs in underserved areas of high diabetes prevalence where DSME programs would not have been available otherwise. However, the participation rate fell to 34% at the 6-month visit and 20% at the end-of-year visit. Some, but not all, program staff members reminded participants of their impending visits by postcard or telephone call.The ADPCP hired an epidemiologist during fall 2002 after the program had formally begun. The epidemiologist engaged key stakeholders and DSME program staff in spring 2003 to plan and implement a program evaluation. Although integrating evaluation early in the program planning process can be very helpful, this is often not done for fear that evaluation will be seen as punitive, exclusionary, and adversarial . This waHealthy People 2010 target to provide diabetes education to 60% of people with diabetes, and 3) the DSME program fostered preventive care practices.Key evaluation issues chosen to assess DSME program outcomes included whether 1) the coalition was able to establish 12 DSME programs in rural underserved counties in Arkansas, 2) the DSME program fostered progress toward achieving the The coalition met its goal of establishing the 12 DSME programs in underserved counties. The number of people receiving diabetes education in Arkansas more than doubled from February 2003 to March 2004. This increase highlights success in addressing diabetes education among the most hard-to-reach populations in the state. Although recruitment efforts for the DSME program had some success, the lack of a unified effort to retain participants, along with reimbursement-related barriers, may have contributed to high rates of attrition.Key stakeholders, including coalition members and DSME program staff, were given the evaluation results. The coalition understood the weaknesses of the follow-up and realized that evaluation should have been incorporated early in program planning. If an evaluation planning process had been incorporated into the early coalition meetings, it may have led to the identification of key barriers and resulted in changes to program content, resources, and timeline. These changes may have, in turn, increased program effectiveness and usefulness of evaluation findings. Another potential limitation is that clinics self-selected to establish the DSME programs. This may limit the generalizability of findings because participating clinics may not be representative of clinics in rural Arkansas.The ADPCP and its coalition members plan to implement six more DSME program sites in underserved rural Arkansas counties by spring 2006. For that purpose, coalition and DSME site staffs will incorporate evaluation planning before the new sites are fully implemented. Developing formative and impact evaluation plans prior to program implementation helps to ensure an evaluation provides useful information. Impact evaluations are used to determine the degree to which a program has led to desired changes and may also have implications for future programs. The coalition will consider which evaluation data are needed from each site to enable a comprehensive assessment of program goals for utility, feasibility, propriety, and accuracy .Program and evaluation efforts for the six new sites will include a review of the evaluation findings of other similar DSME programs to determine how best to address attrition, data consistency, and other key barriers. For example, studies examined attrition rates for diabetes education programs that included a follow-up component ; attritiEstablishing the 12 DSME programs in underserved rural areas of Arkansas provided important lessons about the importance of an evaluation plan. The authors view the development of an evaluation plan as a necessary and valuable initial step toward better addressing the educational needs of people diagnosed with diabetes in rural Arkansas.Even in the face of serious resource challenges, the coalition attempted to address both anticipated and unanticipated barriers. Findings from this program evaluation will affect the establishment of future DSME sites in rural Arkansas. Particular attention will be given to an evaluation plan that embraces fiscal, human, and environmental factors that affect program planning, implementation, and sustainability. Findings from this evaluation may prove useful to others working in medically underserved rural communities throughout the United States.


Practical Program Evaluation: Assessing and Improving Planning, Implementation, and Effectiveness is an excellent first step toward a much-needed program evaluation taxonomy — one that is particularly useful for those new to evaluation, as well as for seasoned evaluators who would like to encourage understanding of the evaluation process. In this four-part, 11-chapter book, Chen discusses the evaluation process from program planning to outcome assessment. He advocates a theory-driven evaluation approach that supports his taxonomy and provides a thorough review of the theory-driven approach. Chen explains that many evaluation concepts are too vague or ambiguous to apply effectively to actual evaluations. He proposes an evaluation taxonomy to exemplify a holistic approach to evaluation practice. The new taxonomy supports evaluators in their attempts to understand and apply evaluation designs, data collection techniques, and use of evaluation information at a practical program level. This is no small achievement and should be an impetus for additional work in the area of evaluation taxonomy development. The taxonomy and overview of the process are excellent tools for strengthening communication between stakeholders and evaluators. The work is replete with diagrams, examples, and definitions and would be a welcome addition to any evaluation course curriculum.Chen states that the intended audience for this book is students who have completed an entry-level evaluation course, as well as seasoned evaluators who would like to expand their knowledge and strengthen their practical skills. He acknowledges that many of the terms and definitions presented are not consistent with terms readily found in the current literature, but he encourages the readers to broaden their understanding of evaluation. For example, Chen discards the logic model in favor of his action-model and change-model approach. Although this could be an interesting challenge for seasoned evaluators, it might prove more of a burden for novice evaluators. In the final chapters, Chen also briefly addresses some criticisms of theory-driven evaluation and challenges evaluation practitioners to think about the politics and contributions of evaluation activities.Chen also skillfully demonstrates that stakeholder theory is a legitimate basis for theory-driven programs and needs to be explained and vetted like established theories of behavior change such as the Health Belief Model. He reminds evaluation practitioners that program theory and the program itself belong to the stakeholders. Chen proposes that the role evaluation practitioners should play varies from one of objective observer to one of a clear partner in the development and design of the program. With these varying roles, the evaluation approach will also change.As with all the strategies and approaches he addresses, Chen provides a thorough discussion of the positives and negatives of efficiency and effectiveness evaluation. Although the book provides an insightful discussion of evaluation in the program planning, development, and maturation stages, Chen does not discuss evaluation use or discern intended users (program stakeholders). The taxonomy presented can guide evaluation practitioners through the conceptualization and implementation of approaches and methods suited to each stage of a program's development. However, it does not provide adequate guidance for obtaining stakeholder questions and evaluation priorities. Chen does argue for the inclusion of stakeholders throughout the evaluation process and proposes that use of the taxonomy will facilitate discussions between evaluators and stakeholders, but this will be derived from the program theory and stage of development rather than from the intended users and projected uses of the evaluation. Chen's discussion of qualitative, quantitative, and mixed methods still helps students conceptualize potential problems and learn how to address them as they read about the abundance of evaluation approaches available. The book is a welcome addition to the expanding literature on evaluation, because it provides an overall conceptualization of the evaluation process from program design to implementation. Although the book is somewhat limited by its lack of discussion about how evaluation results are used, this breakthrough in conceptualization will surely encourage more work in the area.


Increasing the physical activity levels of older adults through diffusion of successful research-based programs into community settings is challenging because of differences between research and real-world settings. This project diffused the Community Healthy Activities Model Program for Seniors (CHAMPS) II, an individual-level research-based physical activity promotion program, through three community organizations to reach lower-income and minority (primarily Hispanic or Latino and African American) seniors.Through an academic–community partnership, university staff worked with each organization to adapt the program to be appealing and effective, enable their staff and volunteers to provide the program, increase participants' physical activity, and leave sustainable programs in place. Evaluation was based on methods recommended by the Centers for Disease Control and Prevention.P = .08] and 437 kcal/week [P = .06] expended in physical activity). Evaluation revealed challenges and unexpected community-level benefits. All organizations are continuing efforts to promote physical activity for older adults.The adapted programs, referred to as CHAMPS III, differed from the original program and among organizations. Group-based components and resource guides were included and new features were added; however, individualized components were not offered because of limited resources. A total of 321 people enrolled among three organizations; there was a trend toward increased physical activity at two organizations (an estimated increase of 481 kcal/week [This project enabled community organizations to implement physical activity promotion programs. The overarching challenge was to retain original program features within each organization's resources yet be sustainable. Although the programs differed from the original research program, they were a catalyst for numerous community-level changes. Our findings can guide similar projects to reach underserved older adults. To address the current public health problem of widespread sedentary behavior among older adults in the United States, numerous initiatives have emerged to promote increased physical activity (PA) ,2. TheseEvidence for the effectiveness of community-level interventions to increase adult PA was reviewed by the Task Force on Community Preventive Services . Two "stMany initiatives emphasize the need to increase PA in underserved populations, such as racial and ethnic minorities or people with low socioeconomic status (SES) ,9, primaOne promising approach to increasing PA among older people in underserved populations is to diffuse into the community successful research-based PA-promotion programs that are consistent with the recommendations of the Task Force on Community Preventive Services and the Best Practices Statement . HoweverThis article reports on a project to diffuse a research-based PA-promotion program, the Community Healthy Activities Model Program for Seniors (CHAMPS) , into thThe goal of CHAMPS III was to evaluate the efficacy of diffusing CHAMPS II by implementing it in three community organizations, adapted to their context and clientele. Specific objectives were the following: 1) to work with staff from participating organizations and community members to adapt CHAMPS II to be appealing, feasible, and sustainable; 2) to diffuse the modified programs by enabling their staff and volunteers to conduct the programs, with training and assistance; 3) to evaluate implementation processes; 4) to increase participants' PA levels; and 5) to leave programs in place at each organization. We describe these processes and challenges as well as ideas for improving translation and diffusion processes in other settings. Our results contribute to a small body of literature on diffusing PA-promotion programs to reach underserved populations.CHAMPS is a lifestyle PA-promotion program for older adults. The choice-based individually tailored program provides information, skills training, support, and problem solving through a personal planning session, regular telephone follow-up, group workshops, newsletters, activity diaries, and functional fitness assessments. Using principles of social-cognitive theory, trained staff members assist participants to develop and maintain a PA regimen of their choice, based on their health, preferences, readiness to increase activity, ability, and resources. Participants are encouraged to join existing community-based PA classes and programs, develop a regimen on their own (with guidance), or both. They learn how to motivate themselves, overcome barriers, exercise safely, develop a balanced program , and progress slowly.For CHAMPS III, the University of California, San Francisco (UCSF) partnered with three San Francisco Bay Area community organizations differing in purpose, size, infrastructure, and clientele. The organizations were as follows:Network for Elders ("Network") in Bayview Hunters Point, San Francisco, provides case management and referral for about 500 frail elders and their families to help elders remain in their homes and reduce isolation. An affiliated interfaith volunteer program provides many services. The city of San Francisco has designated the region as a low-income concentration area and an area of concentration for African Americans and Asian/Pacific Islanders.On Lok's 30th Street Senior Center ("30th Street") in the Mission District of San Francisco provides approximately 250 seniors per day with a range of activities and services to maintain or improve their well-being. Volunteers offer many of the services. The city of San Francisco has designated the region as a low-income concentration area and an area of concentration for Latinos. Sequoia Hospital Health & Wellness Services, a hospital-affiliated outpatient center in Redwood City, serves parts of San Mateo County. It provides wellness programs to promote the independence and well-being of adults, in partnership with physicians. Although its clientele tends to be nonminority (its service area was 38% nonwhite in 2003), it aimed to recruit lower-income, minority older adults for this project.  The organizations were selected to represent different organizational models for program diffusion to reach underserved populations. Selection was also based on a history of collaboration with UCSF faculty working in minority health research. Because extensive time is needed to establish an effective relationship with community-based organizations ,25, thisThe UCSF team had expertise in social work, exercise physiology, health education, and community work. UCSF's role was to 1) help adapt the program to be as similar as possible to the original, 2) develop new program materials, 3) translate materials into Spanish as needed, 4) provide training, 5) monitor implementation, and 6) conduct program evaluation.Physical Activity Evaluation Handbook  and 2 years for implementation and evaluation (November 2000 through October 2002). Planning and adaptation activities included community focus groups on PA attitudes, preferences, and barriers ,30; planWe adapted the program for each organization to maximize safety, feasibility, sustainability, and effectiveness. The original model was not feasible for any of the three organizations selected for this study; thus, during adaptation, we identified the purpose of each component of the original program  and determined whether it could be achieved in a different way. For example, although grant funding was available, 30th Street did not hire an exercise specialist because it was not sustainable. (Volunteers provide many of their programs.) Adaptations continued during implementation based on participant and staff feedback. Planning outputs for each organization are summarized in One challenge was determining appropriate medical screening procedures based on staffing differences and a reduced capacity for providing individual guidance compared with CHAMPS II. Unique situations also had to be considered; for example, most PA classes at 30th Street were historically available without medical screening or consent. Balancing the need for participant safety with the need to reduce barriers to participation also influenced CHAMPS III procedures. The evaluation plan was similar among organizations and included process evaluation to understand adaptation and implementation . Every 6t tests to determine the significance of the changes. Staff also obtained informal input from participants throughout the project, and the Network director conducted a discussion group at the end of the first cohort. The UCSF Institutional Review Board approved a waiver of consent for all evaluation procedures.To measure individual outcomes, interviewers administered the CHAMPS Physical Activity Questionnaire ,32-34 inWe report on the implementation of CHAMPS III as well as initial, intermediate, and long-term outcomes. Initial outcomes include differences between CHAMPS II and the programs offered by each of the three organizations in CHAMPS III and the sociodemographic characteristics of the participants at each organization. Intermediate outcomes were measured at the end of the intervention and included data on participant levels of PA and organization- and community-level changes. Long-term outcomes were measured 1.5 years after funding for CHAMPS III ended.Each organization offered a 6-month program, enrolling two to seven cohorts. During implementation, Network and 30th Street required substantial assistance from UCSF staff, whereas Sequoia conducted its entire program using its own resources. Because PA resources were almost nonexistent in Network's community, developing new resources became an essential part of its program.Feedback from participants and staff and other factors such as community interest resulted in some early recruitment and program modifications. For example, at Network and 30th Street, the initial recruitment plan was adapted to provide "rolling" or ongoing enrollment to accommodate individuals who wanted to join after the program was underway. Only Network provided newsletters but in a modified form. 30th Street created a program bulletin board to display announcements and information. The personal planning session and ongoing telephone support were not offered by any organization because of staffing and budget constraints. In CHAMPS II, these two components enabled personal attention and individualized guidance through discussion of topics such as readiness to change, exercise safety, barriers to PA, resources, and goal setting. Even Sequoia found these components too labor-intensive despite having appropriate staff. Elements from these components were included in CHAMPS III group workshops whenever possible. All organizations used occasional reminder telephone calls; Network also provided check-in calls when participants missed activities. New features were added to some programs, such as a weekly program-based exercise class at Network. This class provided informal support activities, such as sending get-well cards to fellow participants.Intermediate outcomes were measured at the organizational, participant, and community levels immediately after the intervention was completed.Organization-level outcomesThe Doctor Is In sessions , and one to four special events such as celebrations of participants' program completion. Participants could complete fitness testing one or two times. Sequoia's program at each senior center consisted of eight workshops, including two functional fitness testing sessions and a celebration at completion of the program.Each program was unique, and offerings changed as the program evolved and new cohorts were enrolled; thus, the number of activities that were offered varied. Network's cohorts could attend seven or eight exercise- and health-related workshops and a weekly exercise class. Functional fitness tests were offered two times per cohort. Special events like potluck luncheons were held occasionally. 30th Street offered to each cohort six exercise-related workshops, two to three additional exercise- and health-related presentations, five to seven We obtained input on intermediate organization-level outcomes from staff and administrators through process evaluation. A Network administrator noted that although the organization primarily focused on frail elders, CHAMPS III provided an opportunity to reach seniors who were not homebound or as frail as its typical client. The project also brought together public and nonprofit community organizations.30th Street administrators reported positive organization-level changes such as enhanced awareness among staff, volunteers, and seniors of the benefits of PA as well as increased participation in their ongoing exercise classes . The emphasis on increasing PA also attracted younger seniors to the center. Some local physicians referred patients to 30th Street because of increased program awareness. Because of low participation among men, 30th Street hosted a men's conference on the benefits of PA and sought information on what might help them become more active. Efforts were then initiated through the city's recreation and parks department to develop activities suggested by the men. New partnerships provided a channel for sharing information on topics such as potential funding or community resources. Both 30th Street and Network gained access to several academic programs that provided student interns.Sequoia's new approach of offering programs at community senior centers (rather than at its own site) led to increased community awareness and appreciation. Sequoia created new partnerships and strengthened existing ones with several senior centers; they are committed to working together to help maintain seniors' independence.Participant-level outcomes P = .08; +1.9 hrs/week, P = .10) and Sequoia . No statistically significant change in caloric expenditure was observed at 30th Street, but there was a trend toward decreased duration . For the total sample among organizations (n = 207), there was a trend toward increased caloric expenditure . The overall 6-month response rate at Sequoia was low (52%), with 83 of 160 participants completing the follow-up questionnaire; thus, results may not represent all people participating in the Sequoia program. The response rate at Network was 85% (53/62), and the response rate at 30th Street was 72% (71/99).Of the 321 participants enrolled in the three programs, 207 completed baseline and 6-month follow-up questionnaires. Six-month changes in PA are shown in Network obtained an informal evaluation by participants through a one-time discussion group after being in the program for about 6 months. Most of the feedback was positive. For example, the participants particularly liked the group exercise, fellowship, and a chance to meet new people. They felt that the program "helped them help themselves" and perceived both physical and mental benefits. Constructive criticism was also provided; participants felt that the classes and workshops were too short, and they wanted more exercise equipment such as treadmills. Community-level outcomesAt Network, new partnerships with other community organizations developed, enhancing PA resources for seniors. As noted previously, there were no exercise classes available in the Bayview Hunters Point community at the beginning of the program. By the end, there were six: three offered by the local community college, one beginner pool-exercise class, and one African American line-dancing class, in addition to the program's exercise class. One intern helped start a walking group that developed into a partnership between the program, the city's recreation and parks department, and Network's interfaith volunteer group. All of these exercise resources were formally or informally associated with Network's program. Program participants regularly attended the community college classes and helped keep enrollment high enough to sustain the classes. Seniors and staff in Network's program successfully advocated for new chairs, improved lighting, and regular cleaning of the gymnasium where some classes were held. Some enrollees became formally involved with the Trust for Public Land in developing a new community park. The Trust approached the seniors to conduct programs in the park, plan clean-up and planting days, and promote these activities in their community.At 30th Street, a new tai chi class was offered twice weekly and became affiliated with the program, with an average attendance of nearly 40. During the project, Sequoia's staff learned from participants that there was a need for fall prevention; some participants dropped out because they were afraid of falling. Sequoia developed and started teaching fall-prevention and strength-training classes at three senior centers. The new program attracted new clients. One senior center organized a fitness advisory board to determine which fitness and health classes should be offered.San Francisco Chronicle. For 30th Street, a local Spanish-language newspaper included an article about PA for seniors and the 30th Street program.Each program received news media attention that helped expand its reach into the community, although most attention was for Network. A local community newspaper published four articles about PA and Network's program, and the program was featured on KQED  in a prime-time report. The line-dancing class was featured by the Long-term outcomes are defined as those that were measured 1.5 years after the funding for CHAMPS III ended. Ultimately, the success of diffusion programs is determined by their sustained availability to community members; all organizations in CHAMPS III are continuing efforts to promote PA for older adults, despite funding challenges.At Network, five community dance and exercise classes have continued. In addition, Senior Strutters, a performance group that evolved from the African American line-dancing class, often performs at community events. Because of the increased number of seniors at the city recreation and parks department's facility where the program class is held, the department provided a staff member to help with set-up and registration, and an employee now teaches the class, which may help the class continue. Network staff maintains the monthly PA resource calendar discussed previously. These are substantial accomplishments, because the entire program is run by the seniors who volunteer their time to promote and coordinate the program and sustain the exercise classes created in their community; no staff is currently paid to coordinate the program.30th Street obtained funding for 2 years to continue and expand its program. The grant supported a bilingual Wellness Services Coordinator dedicated to the program and provided for two treadmills. In the new program, physician consent was obtained using a new form that enables physicians to indicate which classes offered at 30th Street are appropriate for each individual. This allows the coordinator, without being a trained exercise professional, to tailor the program to some extent for each participant. In addition, 30th Street's tai chi class has continued, and a second advanced class has been added.Mature & Secure From Falls program. Sequoia Hospital offers these programs at no charge. The program has developed into a 6-week community-based class series and has been presented at more than 20 sites in San Mateo County. Sequoia also convened the San Mateo County Fall Prevention Task Force, where 27 organizations providing services to seniors are working to increase awareness about the need for fall prevention and to develop related resources.At Sequoia, efforts have shifted to providing the CHAMPS III provided insight into the process of translating and diffusing a research-based program into diverse community-based organizations to reach underserved older adults. We are aware of only a few studies that have diffused research-based PA programs to reach minority and lower SES subgroups of older adults. The California Active Aging Program was a large-scale effort to reach seniors through a variety of community settings; although not focused on underserved people, it reached a diverse sample . Active Our original intent was to diffuse CHAMPS II with some adaptations to meet the needs of the communities and organizations; however, it became apparent that the program would need to change substantially to be feasible and sustainable. The most substantial changes were the loss of the personal planning session and ongoing motivational telephone support at all three organizations and the lack of a staff exercise specialist at two organizations. Without these components, the programs were not able to provide the ongoing, individual-level guidance and support available in CHAMPS II.We speculated on why we did not observe more changes in PA levels. It is difficult to compare preintervention and postintervention PA changes between CHAMPS III and CHAMPS II because CHAMPS II was a randomized controlled trial. Nevertheless, in CHAMPS II, the 1-year estimated increase of 687 kcal/week in PA among the intervention group  was muchAlso of interest is why Network and Sequoia had trends toward increased levels of PA, but no change or a trend toward decreased PA (depending on the measure) was observed at 30th Street. Many seniors at 30th Street may have joined because they happened to be at the center at the time of enrollment and fitness testing, and they wanted to be part of what was happening that day. At Network, individuals had to go out of their way to join and participate. Some participants at 30th Street did not feel comfortable joining existing classes because they were concerned about exercising with certain medical conditions or limitations; they requested a weekly program class in which they could get guidance similar to that given in the monthly workshops by the exercise physiologist. Network's class was taught by an exercise physiologist and provided social support. Scheduling conflicts related to the participant's transportation to the center, volunteer duties, extended travel to their country of origin, and difficulties with keeping track of when program events were held (because they weren't on a weekly schedule) seemed common at 30th Street and may have contributed to the PA findings.Sequoia's variability in PA changes among cohorts is more difficult to interpret. The variability highlights the unique challenges of collecting evaluation data for a program offered by community organizations (rather than universities such as UCSF). Because program funding was not focused on research, we had to limit paperwork, including questionnaires. Sequoia's lower response rates may have been partially responsible for the variability. Sequoia chose to collect data without assistance from UCSF, making quality control difficult. In fact, Sequoia's staff reported that collecting data on PA was one of the main challenges of the project. At the other sites, extensive efforts were required to collect data; UCSF staff worked closely with organization staff to find participants and administer the questionnaires face-to-face. Overall, it was difficult to provide a practical community-based program while obtaining useful evaluation data. At times, the amount of missing or questionable data precluded our reporting the findings . Future programs should address these issues in the grant-proposal stages. It would help to designate and fund university staff to collect all data.Ideally, more funding should also be allocated toward a more extensive development phase for diffusion project proposals. Although we met with organization administrators before submitting our grant, it was only after the grant was funded and numerous planning meetings took place that both sides truly understood the other's expectations and resources. It then became apparent that UCSF staff would need to play more substantial roles than planned at two sites. This shift raised sustainability concerns, but it was important to support the organizations in offering some version of CHAMPS and observe how it could be sustained. We also learned that some organizations would have preferred to be offered an existing program rather than developing it together; that is, they wanted to get a program going quickly and respond to problems when they emerged. Because much literature emphasizes the need to involve the community in all aspects of planning ,39, we wBased on our experiences, this project succeeded because of at least one enthusiastic staff member at each organization committed to helping seniors with this program. In addition, UCSF staff characteristics that helped were being 1) culturally competent, 2) interested in being involved in the community beyond project demands, 3) creative and patient in overcoming barriers, and 4) able to adapt on a moment's notice. For future projects, it would be helpful to have university or organization staff members serve as a liaison to make connections among resources. In a related study, we found that many community organizations are interested and willing to help in many capacities ; however, someone needs to cultivate relationships and translate intentions into action .We consider the community-level changes effected through implementation of an individual-level program to be the most successful part of our project. This project enabled three organizations to adapt and implement a program to increase PA among minority and lower-income seniors. The three organizations are committed to retaining PA as part of their offerings; Network and 30th Street have sustained some program components, and Sequoia is promoting PA through its new fall-prevention program.The main caveat is that the project was only a first step toward a sustained effort. To adequately diffuse such a program into communities to serve lower income and minority older adults, settings are needed with more infrastructure and capacity, with staff experienced in reaching and working with culturally diverse groups, and with an exercise specialist available to offer parts of the program. An alternative model is to partner with public health departments offering chronic disease prevention programs, where health educators and public health nurses might provide program features with assistance and input from exercise specialists . Public Physical Activity Evaluation Handbook (This article provides an example of applying the program evaluation approach from the Handbook  to a dif