Substance use is highly prevalent among Dutch adolescents. The Healthy School and Drugs program is a nationally implemented school-based prevention program aimed at reducing early and excessive substance use among adolescents. Although the program's effectiveness was tested in a quasi-experimental design before, many program changes were made afterwards. The present study, therefore, aims to test the effects of this widely used, renewed universal prevention program.A randomized clustered trial will be conducted among 3,784 adolescents of 23 secondary schools in The Netherlands. The trial has three conditions; two intervention conditions  and a control condition. The e-learning condition consists of three digital learning modules  that are sequentially offered over the course of three school years . The integral condition consists of parental participation in a parental meeting on substance use, regulation of substance use, and monitoring and counseling of students' substance use at school, over and above the three digital modules. The control condition is characterized as business as usual. Participating schools were randomly assigned to either an intervention or control condition.Participants filled out a digital questionnaire at baseline and will fill out the same questionnaire three more times at follow-up measurements . Outcome variables included in the questionnaire are the percentage of binge drinking (more than five drinks per occasion), the average weekly number of drinks, and the percentage of adolescents who ever drunk a glass of alcohol and the percentage of adolescents who ever smoked a cigarette or a joint respectively for tobacco and marijuana.This study protocol describes the design of a randomized clustered trial that evaluates the effectiveness of a school-based prevention program. We expect that significantly fewer adolescents will engage in early or excessive substance use behaviors in the intervention conditions compared to the control condition as a direct result of the intervention. We expect that the integral condition will yield most positive results, compared with the e-learning condition and control condition.The protocol for this study is registered with the Nederlands Trial Register NTR1516 Dutch adolescents are one of the leaders in terms of drinking frequency and binge drinking in Europe and they usually start drinking in early adolescence . Also, tThe implementation of effective prevention programs is a potential powerful tool to lower the prevalence of substance use in early adolescents and to delay the age of onset of substance use. In the past, many school-based prevention programs have been developed and implemented -12. In gOne of the most well-known and widely used universal prevention programs for Dutch early adolescents is 'The Healthy School and Drugs (HSD)' program. The HSD program combines elements of all three types of school-based prevention and is based on the ASE model -18, whicThe HSD program is a multi-component prevention program aimed at reducing early and/or excessive substance use among adolescents. The program consists of four pillars, which are: information lessons , parental participation, regulation of substance use, and monitoring and counseling of students' substance use. Although scholars argue that multi-component approaches, like the HSD program, are more effective than single component approaches  many DuThe primary aim of the 'Healthy School and Drugs' study is to assess the effectiveness of this multi-component universal prevention program by conducting a randomized clustered trial including 23 Dutch secondary schools. Three follow-up assessments  will be carried out to examine the effects of the intervention conditions. Two hypotheses will be tested. First, in line with prior findings, we expect that the program will lead to a lower likelihood of unhealthy substance use behaviors. We expect that adolescents in the intervention conditions, relative to controls, will be less likely to engage in early or excessive substance use behaviors at follow-up. More specifically, we expect that this effect will be more pronounced in the integral condition compared to the control condition than in the e-learning condition compared to the control condition.Second, following the ASE model, we expect that cognitive aspects of behavior will mediate the effects of the program. Specifically, we expect that adolescents included in the intervention conditions (as compared to controls) will (a) have more knowledge about the -harmful aspects of- specific substances, (b) have more negative and less positive attitudes towards substance use, (c) perceive to have less approval for using substances from their social environment, (d) have more confidence in refraining from use when confronted with tempting substance use offers, and (e) have more adequate risk perceptions concerning the consequences of substance use.The HSD effectiveness study is a 3-year randomized clustered trial (RCT) with three arms - two interventions  and a control condition - testing the prevention program effects. Participants are 3,784 early adolescents of 23 secondary schools from seven different regions in The Netherlands: 1,330 are involved in the e-learning condition, 1,195 in the integral condition, and 1,259 in the control condition. After initial recruitment and enrollment in the trial, randomization took place at the school level, to avoid contamination between conditions . DirectThe HSD program will be implemented after the baseline assessment in different phases to prevent overburdening of schools. In the first year - when adolescents are around 12 years old - the focus in the integral condition will be on starting with the information lessons on alcohol and to get parents involved in the program. In the second year, the schools in the integral condition will implement the two remaining pillars besides the information lessons on tobacco. Finally, in the third year the information lessons on marijuana will be implemented  and Municipal Health Services (MHS). Therefore, we contacted all these institutions to ask for corporation in the effectiveness trial. Seven institutions  agreed to take part in the study and secondary schools were recruited from these regions. All secondary schools in these regions were screened for eligibility. Exclusion criteria were recent involvement  in the HSD program and not offering a four-year education program. All eligible schools received an invitation letter and an information brochure and were contacted after two weeks to discuss participation in the study. Participants were thus recruited by school participation and all first grade students of participating secondary schools were included in the study. We visited the participating schools and during these visits further information was provided about the research project. In collaboration with the schools' headmasters, we informed the students' parents annually about the goals of the study by a letter in which parents were also notified that they could refuse participation of their child in the study. Thus, a passive informed consent procedure is followed in which parents (and their children) can refuse study participation by email, telephone or in person during the entire study period. Approval for the design and data collection procedures was obtained beforehand from the ethic committee of the Radboud University Nijmegen.Randomization occurred at the school level to avoid contamination between conditions. Thus, all first grade students from one school were allocated to the same condition . An independent statistician performed the allocation before baseline assessment. Randomization was carried out centrally, using a blocked randomization scheme (block size 6) and stratified by level of education the schools offered.d) of. 15 [We estimated our targeted sample size based on a small effect size  of. 15 . As the ) of. 15 . We usedThe HSD program is a multi-component, school-based prevention program aimed at reducing excessive and early substance use among adolescents. The program for secondary schools consists of four pillars, which are:1) Information lessons (e-learning modules): e-learning modules were developed for the information part of the program. These digital modules connect well to the experience of adolescents. Students work through the modules in their own pace during biology or counselor lessons, or in a special project week. The lessons pay attention to knowledge, attitude, and behavior with regard to substance use. Besides tutoring the students about the risks concerning substance use, students are also prepared for coping with group pressure by training their refusal skills. The modules consist of small films, animations, and several types of interactive tasks and identification is a central part of the modules. Also, adolescents are able to discuss relevant topics or to exchange their opinions through chat rooms and forums. Students receive three modules: alcohol (4 lessons), tobacco (3 lessons), and marijuana (3 lessons) in the first, second, and third grade, respectively. The lessons and modules are designed to gradually increase adolescent's skills in responsibly dealing with substances. Teachers are trained in the content and operation of the digital modules before the lessons are offered to the students.2) Parental participation: Parents of first grade students are invited to attend a parental meeting in which information will be provided about the HSD prevention program and the relevant substances. Also, parents will be informed throughout a parental brochure and the school newsletter. The parental meeting will be held at school in collaboration with the ITCD or MHS. The duration of the parental meeting will be approximately 90 minutes. First, in a brief opening the attention of parents is captured by facts on substance use in adolescence. Then, brief information on the school regulation on substance use is provided. Characteristics and risks of substance use, opinions on substance use, and education in the home setting with respect to substance use will be discussed in the remainder of the meeting.3) Regulation: the idea behind this pillar of the program is that rules set boundaries and create clarity. Therefore, the school needs to set an adequate regulation standard and rules concerning substance use behaviors of students and personnel. If the school lacks such regulation a special team will be instigated, including all relevant parties . This team will create or revise the rules and will plan how to communicate and maintain the rules in and around school. The school team will be assisted by the ITCD or MHS during this process.4) Monitoring and counseling: An operation protocol (if absent) is to be formulated on how to deal with problematic substance use behaviors among students. Also, the ITCD or MHS will provide a training session on signaling and guiding problematic substance use among individual students. This training is meant for teachers, mentors, student speculators, and the care coordinator(s) of the school. During this training session practical information will be provided on how to recognize problematic use in students and on how to efficiently support these students. Further, advice will be given on how to use the operation protocol in daily practice.The information lessons of the HSD program are based on the ASE model -18, whicThe ASE components are imbedded in the e-learning modules and students work through these ASE components via the principles of information theory. First, effects of information lessons are only expected if students are tuned to the message, so the information should capture the attention of the students and should match the information needs of the students. Special triggers to capture students' attention (stories that students can identify with) are incorporated in the materials. Second, a message can only be effectively communicated if students understand the message. Information is therefore provided in a way that corresponds with the realm of adolescent thought by using age appropriate language and tasks. Third, becoming aware of attitudes and to influence these attitudes in the direction of the desired behavior, information is conceptualized as trustworthy and attuned to the student's opinions. Students are asked to think about pros and cons of substance use and are encouraged to make judgements themselves. Fourth, to account for the influence of the social environment, students are trained to resist social pressure. With the help of specific tasks on social norms, students are invited to think about social norms on substance use. Also, example videos are used to display how adolescents are influenced by others. Fifth, self-efficacy will influence actual behavior of students, thus students should be confident in their refusal skills. Students therefore learn how to carry out the desired behavior, and how to maintain and incorporate these behaviors into their daily living environment with the help of special processing tasks. Finally, students should persist in the desired behavior. Feedback on own behavior is important to achieve this goal, because it makes students aware of positive effects of their (changed) behavior. Students are challenged to think about what they will gain if they do not use a specific substance (just yet). All these information principles are processed in the design of the e-learning intervention by the following route: what happened (1), what do you know (2), what would you do (3 to 6). In total, adolescents work through this process three times; first for alcohol, then for tobacco, and finally for marijuana. Although the focus of the substance changes over the years, booster effects for the e-learning modules are expected because the training process is repeated.The HSD prevention program is based on the assumption that more than information lessons are necessary to prevent adolescents from unhealthy substance use behaviors. Adolescents need rules and tutoring, a task for parents, school boards, teachers, and student counselors ,14. The The participating secondary schools were randomly assigned to one of the three following study conditions:1) E-learning: Secondary schools that only carry out the e-learning modules. These schools will provide the information lessons in our target group.2) Integral: Secondary schools that carry out the entire HSD program. These schools will also provide the information lessons in our target group, but also carry out the other three pillars of the HSD program.3) Control: Secondary schools that do not carry out prevention activities. These schools are characterized by 'business as usual'. Many schools in The Netherlands have employed initiatives concerning substance use. The schools can carry on with these initiatives, as long as no HSD activities are carried out in our target group (both students and school personnel).For the duration of our study, all participating schools, including those in the control condition, agreed not to implement or carry out other substance use prevention programs in the target group.An overview of all measurements is given in Table The HSD prevention program targets reduction of substance use among adolescents. Since the program focuses on alcohol, tobacco, and marijuana use, we operationalized attainment targets for all three substances. The primary outcomes for alcohol are defined as the percentage of binge drinking , the avDescriptive analyses will be conducted to check whether randomization has resulted in a balanced distribution of important student characteristics in all three conditions. Possible confounders will then be included in subsequent analyses to control for potential bias. Because the data have a multilevel structure , the possibility exists that the individual respondents are not independent within schools. To correct for the potential non-independence (complexity) of the data, the TYPE = COMPLEX procedure in Mplus will be used. This procedure corrects the standard errors of the parameter estimates for dependency leading to unbiased estimates.For the main analyses, data will be analyzed in accordance with the intention-to-treat principle and in a completers-only framework by using Mplus , while cThe recruitment, inclusion, and randomization of participants  started in the fall of 2008. The final follow-up measurement is planned for the fall of 2011. The baseline data is collected between January and March 2009. The data of the follow-up measurements will be collected at three fixed time points. These assessments will take place between September and November 2009, September and November 2010, September and November 2011 respectively. Short-term results will be reported before the completion of the 32 months follow-up.The present study protocol presents the design of a randomized clustered trial evaluating the effectiveness of the 'Healthy School and Drugs' prevention program. This universal prevention program aims at reducing excessive and early substance use in adolescence. It is hypothesized that adolescents in the intervention conditions will be less likely to engage in early or excessive substance use behaviors at follow-up compared to the control condition.An important first strength of the Healthy School and Drugs program itself is that it is previously suggested that the program is partly effective in The Netherlands . AnotherA strength of the study design is that it does not only assess immediate effects, but also includes follow-up measurements at 8, 20, and 32 months. This allows us to test both the short and mid-term effects of the HSD program. Second, the extra study condition  will give the opportunity to optimally inform regional ITDC, MHS, and schools about the cost and benefits on their current prevention activities. Also, if the HSD program is found to be effective, the program might be (compulsory) implemented in more schools across The Netherlands, since present govern policy strongly encourages the implementation of effective intervention programs.A limitation of the study is that information on the behavior of adolescents and their environment is entirely based on self-reports of the adolescents, which might lead to measurement errors. Two perspectives can explain possible measurement errors in self-reports on substance use, namely a situational and a cognitive perspective . The sitBased on the results of the HSD effectiveness study, the prevention program will be adjusted accordingly. If necessary the content of the program will be renewed, as will the theoretical concepts and the different parts  of the prevention program. In short, the results will drive the (re)development of the HSD program in the next couple of years.This study will evaluate a multi-component school-based prevention program on substance use in adolescence. The results of this study will provide insights into the effectiveness of the Healthy School and Drugs prevention program and the precursors of substance use among Dutch early adolescents.Karin Monshouwer and Jeroen Lammers work for the Trimbos-institute, which is the institution that developed the 'Healthy School and Drugs' project. Also, this institution is principal for the effectiveness study. The other author(s) declare that they have no competing interests.MM is responsible for the data collection, data analysis and for reporting the study results. All others authors are supervisors and grant applicators. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1471-2458/10/541/prepub


We have compared the unique features of teen tobacco cessation programs developed internally by community-based organizations (N=75) to prepackaged programs disseminated nationally (N=234) to expand our knowledge of treatment options for teen smokers. Internally-developed programs were more likely offered in response to the sponsoring organization’s initiative ; had fewer trained cessation counselors ; and were more likely found in urban areas . Internally-developed programs more often provided other substance-abuse treatment services than prepackaged programs and addressed other youth-specific problem behaviors (p≤0.05). Studies that examine the effectiveness of internally-developed programs in reducing smoking and maintaining cessation for teen smokers are warranted. With st graders . Nationa graders . Most te graders .Teen smoking cessation treatment  often consists of group-based counseling or behavioral interventions offered over the course of several sessions, and it mirrors the content and structure of adult cessation programs . A recenCommunities have been mobilized to reduce smoking among teens and have been at the center of several large, statewide comprehensive efforts to control tobacco use . What isThough the treatment programs profiled in HYSQ collectively had homogenous characteristics, an examination of internally-developed treatment programs is warranted. The current paper goes beyond that of Curry and colleagues by providing an in-depth examination of the local initiatives and programmatic efforts developed in applied community-based settings to assist teen smokers in quitting. Characterizing these programs may provide insight about the local communities’ perceived priorities regarding teen smoking cessation; about the organizational context in which the program was offered; and about the program implementation and delivery. Finally, closer examination of internally-developed programs may help us understand if what is known to be effective for teen smoking cessation in research settings is being practiced in community-based settings. The purpose of this paper is to characterize the unique features of internally-developed programs from several perspectives, including: characteristics of communities where these programs were found ; characteristics of the sponsoring organization ; and delivery and content of the programs. Phase I of HYSQ did not collect data on participant smoking cessation outcomes . Though we are unable to determine if the internally-developed programs were efficacious for cessation, understanding the characteristics of internally-developed programs will expand our knowledge about available treatment options for teen smokers. To highlight the unique features of the internally-developed programs, we compare their community and organizational context, and program delivery and content to that of prepackaged programs.2.2.1.et al. [HYSQ is a multiphase, national initiative that addresses the critical need to disseminate effective, developmentally appropriate cessation programs for teen smokers. The first phase of HYSQ involved a national survey of existing community-based teen smoking cessation programs. Data for this paper come from that survey. Additional details regarding the design and sample process of the overall study can be found in Curry et al. .2.2.A two-staged sampling design with United States counties as the first-stage probability sampling units was employed in this study. From this design, a total of 408 counties were selected to participate in the study. Next, snowball sampling was used in the 408 counties to identify administrators of tobacco cessation programs for teens. A total of 1,347 possible program administrators were identified through the snowball sampling procedure .2.3.The 1,347 administrators were screened to determine eligibility as teen smoking cessation programs to be included in the study. A program was eligible if it was a teen smoking cessation program not a part of a research initiative that was established at least six months prior to the HYSQ evaluation and provided smoking cessation services to persons aged 12–24 years. Based on these criteria, 756 teen smoking cessation programs from 255 of the 408 counties were eligible to be included in the study.2.4.http://www.helpingyoungsmokersquit.org/.Administrators of eligible teen smoking cessation programs were contacted and asked to participate in a 45-minute telephone interview that included questions about community context; organizational setting; participants; program delivery; program content and program evaluation. The telephone interview was administered by the University of Illinois at Chicago, Survey Research Laboratory. Program administrators received a paper copy of the survey prior to the telephone interview. A copy of this survey can be obtained at Of the 756 eligible programs, program administrators from 591 teen smoking cessation programs completed the survey (78.2%). Reasons for not completing the survey included: respondents unavailable to complete the survey; respondents refused to take the survey; and/or respondents could not be reached after multiple attempts.2.5.The telephone survey completed by program administrators included questions about community context; organizational setting; participants; program delivery; program content and program evaluation. No outcome measures  were included in this survey. Community context questions asked about the perceived concerns facing teens; local priorities regarding teen smoking cessation among community leaders; and program awareness and support of the teen smoking cessation program within the community. Organizational context questions (or characteristics of the sponsoring organization) asked program administrators about the primary reason for offering the teen smoking cessation program; the adequacy of funding for the organization; and staffing of the sponsoring organizations. Program content measures included questions about the inclusion of cessation strategies , content addressing other youth-specific issues , youth treatment for other substances , medication use , use of incentives, and use of websites or quitline adjuncts. Program delivery measures included questions about the program operation , program format , physical setting of the program, and enrollment criteria . Participant recruitment and retention measures asked about the number of youth who were serviced by the program in the last 12 months and the number who completed the program in the last 12 months.Measures of county stratification variables were also included. County stratification variables included county urbanization, socioeconomic status (SES), smoking prevalence, and per capita tobacco control expenditures. County urbanization was defined by U.S. Census Bureau metropolitan statistical area (MSA) and consisted of two categories: urban areas (MSAs) and rural areas (non-MSAs). SES was defined by federal poverty level, based on the 2000 Census data and had two categories: high SES (defined as state poverty level ≤ 20%) and low SES (defined as state poverty level > 20%). Smoking prevalence was defined by rates above the national median  and was categorized as: high  or not high . Tobacco control expenditures were categorized by tertiles into high, medium, and low expenditures.2.6.Prevalence of internally developed and prepackaged programs in the community strata was examined using chi-square tests. We investigated the bivariate associations of community context, organizational context, programmatic content, and implementation with internal and prepackaged programming. Next, we performed multivariate backward selection logistic regression to determine the best correlates of internal and external programming. Variables that were statistically significant (p≤0.05) at the bivariate level were included in the multivariate analyses. Analyses were conducted using SAS version 9.1.3.3.1.Of the 591 eligible programs that completed the survey, 374 (63.4%) reported that their organizations used smoking cessation materials developed by an external or parent organization (‘prepackaged programs’). When asked to name the specific prepackaged program used, just over half of the administrators (51.3%) reported using the American Lung Association’s Not-On-Tobacco (NOT) program. The two other prepackaged programs named most often were the Tobacco Education Group/Tobacco Awareness Program (TEG/TAP) (16.3%) and the “American Cancer Society” program (7.4%). The NOT  and TEG/3.2.Compared to those using prepackaged programs, organizations that developed their own cessation program internally reported that their program was more likely to be offered in response to the initiative of the organization. Those organizations that developed their own treatment programs internally were less likely to report having adequate sources of funding. They were also less likely to have counselors trained specifically in teen smoking cessation, and more likely to report program delivery by physicians and certified health educators compared to those organizations using prepackaged programs. On average, both organizations using internally-developed programs and those using prepackaged programs had one paid full-time equivalent (FTE) of staff working with the program.Administrators of both internally-developed programs and prepackaged programs reported that obtaining sufficient enrollment of participants was very challenging; those using prepackaged programs were more likely to endorse this than those using internally-developed programs. Other challenges experienced by both included: obtaining follow-up information on participants, obtaining sufficient funding, hiring appropriate staff for the program, and keeping participants in the program. Despite these challenges, about three-fourths of administrators from both internally-developed and prepackaged programs indicated they were “very likely” to be operating in one year.3.3.3.4.There were several differences in program content between internally-developed and prepackaged programs. Internally-developed programs were more likely than prepackaged programs to address other youth-related issues, such as other drug use, life goals , and violence or gangs. Similar to prepackaged programs, internally-developed programs included state of the art cognitive-behavioral strategies, such as self-monitoring, disrupting smoking patterns, and coping skills training. These programs were also less likely than prepackaged programs to offer incentives overall to participants.3.5.Characteristics that distinguished internal and prepackaged programs in the bivariate analyses were entered into a multiple logistic regression model to determine the best correlates of cessation programming. Of the 234 prepackaged programs and 75 internally-developed programs, 58 observations from the prepackaged programs and 10 observations from the internally-developed programs were removed from the analysis due to missing values for the responses or the explanatory variables (68/309 or 22% loss). The analysis was conducted on the remaining 176 prepackaged programs and the 65 internally-developed programs. Results are presented in State-level smoking prevalence no longer significantly distinguished internal and prepackaged cessation programming in the multivariate model. County urbanization remained a significant correlate of cessation programming, with internally-developed programs more likely to be found in urban (MSA) areas. Similar to the bivariate analyses, the multivariate analyses indicated that organizational characteristics such as offering a program in response to an initiative of the organization, having counselors trained in cessation, and having physicians on the program’s staff remained significant correlates of cessation programming; including certified health educators and enrollment challenges were no longer significant correlates.Bivariate analyses suggested that the content of internally-developed programs more often included topics related to other youth development issues and also included recommended state-of-the-art cessation strategies. Addressing other youth-related issues was no longer a significant correlate of cessation programming in the multivariate model, however. Only the cessation strategy, keeping diaries of smoking, was a significant correlate of cessation programming. No program delivery characteristics were significant correlates of cessation programming in the multivariate model.4.The purpose of this paper was to describe the characteristics of internally-developed programs, compared to prepackaged programs, specifically examining the community and organizational contexts in which the programs were offered, and the delivery and content of the smoking cessation programming itself. Compared to prepackaged programs, our findings suggest that there were some unique features of the internally-developed programs with regard to the community and organizational contexts in which they were offered, as well as in the content of the programs.Internally-developed programs were more often found in urban communities. Our data precluded an explanation of why these programs appear to be more prevalent in urban communities, however. As might be expected, internally-developed programs were more likely created in response to the initiative of their sponsoring organization than in response to state legislation or a health department or department of education initiative. Although the data did not permit us to examine additional reasons why some organizations chose to develop their own programs in light of available prepackaged programs, our findings allowed us to speculate possible scenarios. Organizations that developed their own cessation programs internally were more likely to report fewer resources, such as fewer trained cessation counselors, compared to those using prepackaged programs. Perhaps fewer resources affected the ability of some organizations to obtain and fully implement prepackaged programs. Some sponsoring organizations also may have developed their own programs to better suit the needs of their participants. Bivariate analyses suggested that internally-developed programs were more likely to address other youth-related issues, such as other drug use, life goals, and violence or gangs. Perhaps organizations that developed cessation programming internally served high-risk teens who were dealing with other youth-related problem behaviors and issues in addition to tobacco use. That these programs included content on many health issues may suggest that less tobacco cessation content was provided to teens, compared to prepackaged programs. Continued investigations regarding why some chose to develop their own cessation programming internally and if less cessation content was provided to teens warrants further study.Other unique features of internally-developed programs include criteria for enrollment in the program, the programmatic content itself, and the presence of physician staff. Although mandated participation is relatively uncommon in research-based teen smoking cessation treatment programs ,14, it wThough unique features were present, there were a number of similarities between internally-developed and prepackaged programs. With regard to community and organizational context, reported community priority and support for teen tobacco control was similar among organizations using either internally-developed or prepackaged programs. Organizations that reported using either program type reported similar challenges, such as obtaining sufficient enrollment. There were also similarities with regard to program delivery and content. Similar to prepackaged programs, our results indicated that internally-developed programs utilized programmatic strategies known to be effective in reducing smoking among teens. For instance, internally-developed programs were offered in multiple-session groups in school-based settings, similar to prepackaged programs. Likewise, internally-developed programs in our sample included cognitive-behavioral cessation components in their content, though to a lesser degree than the prepackaged programs. Current youth smoking cessation guidelines recommends the use of cognitive-behavioral treatment approaches to help teen smokers quit , 13 and Although the current study extends our knowledge regarding the characteristics of internally-developed programs, there are limitations. As noted earlier, the survey did not assess tobacco use or smoking cessation outcomes of the participants. As reported by Curry and colleagues , the aimIn conclusion, our findings suggest that there are unique features of teen smoking cessation programs developed internally by local community-based organizations. These findings have several implications for practice and research. Internally-developed programs incorporated some state-of-the-art efficacious components into their treatment, implying that evidence-based research practices are being applied in practice settings. Program providers in local communities that have the support of their sponsoring organization should be encouraged to develop cessation programming that includes these efficacious components and evaluate them as implemented to determine program efficacy. To facilitate the adoption of effective practices in community settings, there is a need for program developers and researchers to collaborate to develop cessation programming. Researchers can provide training and technical assistance in the development of evidence-based treatments to community-based program providers who are interested in developing their own programs to meet the needs of their participants and their sponsoring organizations. Research studies are needed to obtain representative samples of internally-developed programs to further examine their impetus for development. For instance, these studies may examine the ability and willingness of community-based program developers to implement prepackaged programs. Studies are also needed to examine the impact of these programs on teen smoking cessation outcomes , particularly the ability of these programs to either enhance or result in a loss of effectiveness compared to prepackaged programming.


Implementing quality improvement programs that require behavior change on the part of health care professionals and patients has proven difficult in routine care. Significant randomized trial evidence supports creating fall prevention programs for community-dwelling older adults, but adoption in routine care has been limited. Nationally-collected data indicated that our local facility could improve its performance on fall prevention in community-dwelling older people. We sought to develop a sustainable local fall prevention program, using theory to guide program development.We planned program development to include important stakeholders within our organization. The theory-derived plan consisted of 1) an initial leadership meeting to agree on whether creating a fall prevention program was a priority for the organization, 2) focus groups with patients and health care professionals to develop ideas for the program, 3) monthly workgroup meetings with representatives from key departments to develop a blueprint for the program, 4) a second leadership meeting to confirm that the blueprint developed by the workgroup was satisfactory, and also to solicit feedback on ideas for program refinement.The leadership and workgroup meetings occurred as planned and led to the development of a functional program. The focus groups did not occur as planned, mainly due to the complexity of obtaining research approval for focus groups. The fall prevention program uses an existing telephonic nurse advice line to 1) place outgoing calls to patients at high fall risk, 2) assess these patients' risk factors for falls, and 3) triage these patients to the appropriate services. The workgroup continues to meet monthly to monitor the progress of the program and improve it.A theory-driven program development process has resulted in the successful initial implementation of a fall prevention program. Falls are common in older people, occurring annually in one quarter to one third of community-dwelling adults age ≥ 65 . These fClinical practice guidelines recommend multifactorial fall prevention strategies for patients at high risk of subsequent falls . HoweverThis study conforms to the ethical principles in the Helsinki Declaration, and received ethics approval from the VA Greater Los Angeles Healthcare System (PCC 2008-010128) and University of California at Los Angeles (G08-06-103-01) Institutional Review Boards. Because of the minimal risk nature of this project, the Institutional Review Boards waived the requirement for written informed consent.The Veterans Affairs Greater Los Angeles Healthcare System (VAGLAHS) is an integrated healthcare system serving veterans living in a catchment area that spans the metropolitan Los Angeles area. The system includes one acute care hospital with clinics, two community living centers, two ambulatory care centers offering primary care and some specialty services, and ten community-based outpatient clinics that offer mostly primary care. VAGLAHS serves a disproportionately older population; nearly one-quarter of all patients are age ≥ 75, and therefore, a large group of VAGLAHS patients are at risk for falls. In absolute terms, VAGLAHS served a total of 19,257 unique patients age ≥ 75 in its primary care clinics over a two-year period  (unpublished data).VAGLAHS is a globally budgeted, capitated healthcare system. Virtually all healthcare providers are salaried, and all clinicians use a shared electronic health record. VAGLAHS is one of five healthcare systems in the Desert Pacific Healthcare Network, which serves Southern California and Southern Nevada. This network, which finances VAGLAHS' operations, is one of 21 networks in the United States Veterans Health Administration (VA).The national VA Office of Quality and Performance runs the External Peer Review Program (EPRP) to monitor the quality of care provided by VA facilities. In the case of fall prevention, quality indicators previously developed by the RAND Assessing Care of Vulnerable Elders (ACOVE) project  wereThere are two supporting indicators for fall prevention: the first indicator states that outpatients age ≥ 75 should be asked about falls in the preceding year. To determine adherence to this indicator, medical record reviewers are asked: "Within the past twelve months, was the patient asked about the presence/absence of any falls within the preceding 12 months?" The second indicator states that a basic fall evaluation should be performed on outpatients age ≥ 75 with two falls, or at least one fall with injury requiring treatment, in the past year. To determine whether a basic fall evaluation was performed, reviewers search the medical record for documentation of five elements: 1) circumstances of the fall, 2) medications the patient is taking, 3) relevant chronic conditions, 4) diagnostic plans/therapeutic recommendations, and 5) documentation of action taken as appropriate. Although these quality indicators are monitored at the national level, they are not in the first tier of performance measures for which VA managers are held accountable. However, facility-level quality of care scores for these indicators are available internally to VA managers, clinicians, and researchers on the VA Intranet. In addition, through a data use agreement, researchers may obtain more detailed data from the Office of Quality and Performance.We obtained data for the first quality indicator for falls - asking outpatients age ≥ 75 about falls in the past year -- for Fiscal Year 2007 , the first year during which these data were collected. There was marked variation between VA facilities (such as VAGLAHS) in how often outpatients age ≥ 75 were asked about falls in the past year  in the past year - was satisfied in 36% of eligible cases nationally (Patient N = 899). The sample size for this indicator was too small to compare our local facility performance to the national average. However, this indicator is coupled to the previous one - asking more adults age ≥ 75 about falls in the preceding year (indicator #1) will result in the detection of more high-risk cases requiring a basic evaluation (indicator #2). Thus, improving the quality of care for falls at our facility requires both better detection of patients with a significant fall history and better ways to address fall risk factors among high-risk patients.Table In order to improve the quality of care for fall prevention provided to outpatient veterans at VAGLAHS, we envisioned a program development process that would harmonize stakeholder interests towards the goal of producing a pilot fall prevention program that could be implemented, sustained, and further improved. In keeping with previous work on translating research into practice , we drewOrganizational theory helped us conceptualize the initial phase of program development. We drew upon a typology of organizational responses described in Oliver's "Strategic Responses to Institutional Processes" . Oliver Oliver's framework and previous efforts at priority-setting in the VA system  suggesteThe first step of the program development plan involved holding an initial meeting with VAGLAHS leadership, including the Chief of Staff . The goal of this first meeting was to ascertain whether managers within VAGLAHS agreed on a) the importance of fall prevention b) the strategies for preventing falls among community-dwelling veterans, and c) a broad outline of how these strategies might be accomplished. The first author's role in this process was to present evidence from the research literature about strategies for fall prevention, as well as the data on VA national and local performance in fall prevention, discussed earlier.In our original program development plan, the next step was to hold focus groups of patients and employees who would likely be involved with the program. We did not hold these focus groups for two reasons. First, we did not hold focus groups of employees because we received feedback that employees might not be comfortable speaking candidly in the presence of other employees in the same organization. In addition, since the lead author had already conducted one-on-one interviews with multiple different employees prior to program development, re-interviewing employees seemed likely to have less incremental benefit than we originally had envisioned. Regarding patient focus groups, our status as a research study meant the need to obtain Institutional Review Board approval of focus group content and would have lengthened the program development process by three to six months. Since the program development process moved faster than anticipated, we decided not to pursue patient focus groups. Instead, we decided to use patient and stakeholder interviews to evaluate the first cycle of program development (discussed later).The third step of the program development process was to constitute a workgroup of representatives from different disciplines involved in fall prevention to create a concrete plan. We aimed to identify workgroup members who represented the interests of various stakeholders, could provide insight regarding institutional norms and resources, and comprised a mix of content experts in fall prevention and clinicians and practitioners of quality improvement.The fourth step was to hold a second leadership meeting to present the workgroup's suggested plan and receive feedback. Compared to the first meeting, this second meeting would be more focused on discussing specific options for the content of the fall prevention program, based on the findings of the workgroup.Oliver's framework helped in choosing a program development and implementation process but did not directly address characteristics of a program itself that would make it more likely to be implemented successfully, issues that would matter to the workgroup. We used a systematic review of diffusion of innovations by Greenhalgh  to ident• Simplicity--simpler innovations are more likely to be adopted than complex innovations• Trialability--innovations that can be tested and experimented with are more likely to be adopted• Observability--If adopters can see the benefits of an innovation, the innovation will be more easily adopted• Reinvention--innovations that can be modified or refined to suit adopters' needs are more likely to be adopted• Risk - innovations that are less risky are more likely to be adoptedIn conformance with the principle of simplicity, we decided that any research on the program should not interfere with program delivery. In keeping with the principles of trialability, reinvention, observability, and risk minimization, we envisioned program implementation as being consistent with continuous quality improvement methodology, specifically including several concepts described by Locock:• "Continuous incremental improvement of current processes--repeated testing and evaluation of small scale changes.• Responsibility for quality in the hands of frontline staff.• Collective team responsibility.• Detailed meticulous measurement." This continuous quality improvement process would take place on an ongoing basis as the program was implemented.The first leadership meeting (in February 2008) began with a ten-minute presentation of national data Figure  and faciThe workgroup first met in April 2008, and consisted of at least one representative nominated from each of five departments: primary care, nursing, geriatrics, physical medicine & rehabilitation, and performance improvement. The first author, a researcher and clinician, served as a content expert regarding the evidence base for fall prevention. The workgroup met monthly and was attended by five to seven people at any given meeting.The first workgroup session involved brainstorming. Subsequently, a confidential ballot was sent by e-mail to workgroup participants to rank ideas from the brainstorming session, as well as some additional ideas that had come up in the interim  a standard set of scripted questions to assess risk factors for falls, such as whether the individual has impaired vision, gait or balance problems, or need for home modifications  as well as which individuals will most commonly make referrals . Another area that requires additional exploration is the best way to routinely track completion of recommended activities  for patients who participate in the program. In addition, a new phase of the program, encouraged by workgroup participants, is starting , as well as to discuss new ideas. Five to nine participants typically join each call.In addition to the ongoing evaluation that occurs as part of the Telecare fall prevention program itself, a research evaluation of the Telecare fall prevention program is planned. This research evaluation will involve reviewing a log to see how many individuals were screened for the program, as well as performing interviews with patients who participated in the program. The evaluation will also interview stakeholders who help run the program, refer patients to it, or are referred patients from the program. We will assess interviewees' satisfaction with the program as well as solicit ideas for improvement. The evaluation will also review patients' medical records to assess how well the pilot program is being implemented, as well as the overall quality of care patients received for fall prevention. Medical record review will use quality indicators for care of vulnerable older adults with falls and mobility disorders , for whiMultifactorial fall programs are complex to implement in the outpatient setting because they require cooperation between multiple healthcare professionals as well as changes in patients' behavior. A recent organizational survey of managers in the United Kingdom attests to the difficulties in implementing multifactorial fall prevention programs in routine care, even when there is a national mandate to do so . With reWe have some early observations about program development. First, our program development and implementation process has been non-linear. For the first six months, the workgroup's intensity of effort was quite high, and then settled into a maintenance phase after implementation of the program had begun. Second, program development was a hybrid of "bottom-up" and "top-down" approaches . AlthougThird, the program development process unfolded over the good part of a year, and we are still early in the process of implementation. Although slow, this pace is likely to improve sustainability, since participants carry out their program-related duties as part of their usual workload. Fourth, we lack easily obtainable metrics to determine whether care is improving. This contrasts with inpatient fall prevention programs, where data on fall and injury rates are often captured as part of adverse event reporting systems, and can be tracked quarterly to measure response to incremental changes made to improve care. In the outpatient setting, it can be difficult to capture detailed data on falls without turning a quality improvement program into a research study, since most falls in community-dwellers occur outside the four walls of the healthcare system and may not be reported by the patient to a health care provider until months after the fall occurred. Instead, we are relying on continuous quality improvement strategies on a real-time basis to monitor intermediate steps in the process of care, such as completion rates for home safety evaluations that are ordered. In the future, it may be possible to shorten improvement cycles with real-time measures of quality of care for falls using electronic health record data.Last, we anticipate new questions with regard to diffusion and dissemination of the program should our initial evaluation of the program prove positive. Even though our program development process uses existing staff to implement the program, we still benefit from highly motivated individuals who have willingly taken on new duties to improve the quality of care. Although participants in the workgroup may have participated because of a supervisor's request, the degree of participants' involvement has been determined by their own level of interest in and commitment to fall prevention. Extending quality improvement activities beyond the immediate environments that can be affected by workgroup participants to other areas of our system could prove challenging. When we have our initial evaluation results, we plan to re-approach our facility's clinical leadership and discuss possible next steps for diffusion and dissemination.Our program development process is proving sustainable thus far. Since its inception, the multidisciplinary workgroup has continued to meet monthly. The goal of the program development process was to create an initial effort that was sustainable enough to demonstrate a small success to our organization, generating goodwill and the opportunity to improve the program over time, in keeping with continuous quality improvement principles . By thesThe authors declare that they have no competing interests.DAG, EMY, DS, and PGS developed the conceptual framework for the program development and implementation process. EMY and DG analyzed the External Peer Review Program data. DAG drafted the manuscript. EMY, DS, and PGS provided comments for critical revision of the manuscript. All authors read and approved the final manuscript.The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/1472-6963/9/206/prepubInstructions and ballot sent to workgroup participants.Click here for filePatient script used by Telecare Tuck-In nurse.Click here for fileDescription of new fall prevention program elements, including nurse clinical reminder to assess fall risk in patients age ≥ 75 and electronic health record menu options for fall prevention.Click here for file


These gradients (ΔSO2 and Δ[Lac]) are probably created by diluting SVC blood with blood of lower SO2 and [Lac]. We tested the hypothesis that ΔSO2 and Δ[Lac] result from mixing SVC and inferior vena cava (IVC) blood streams.Decreases in oxygen saturation (SOn = 9) who were about to undergo right heart catheterization. Catheters were advanced under fluoroscopic guidance into the IVC, SVC, right atrium, right ventricle, and pulmonary artery. Samples were obtained at each site and analyzed for SO2, [Lac], and glucose concentration ([Glu]). Analysis of variance with Tukey HSD test was used to compare metabolite concentrations at each site.This was a prospective, sequential, observational study of hemodynamically stable individuals with pulmonary artery hypertension . SO2 and [Lac] in right atrium, right ventricle, and pulmonary artery were similar. ΔSO2 was 4.4 ± 1.4% (mean ± standard deviation) and Δ[Lac] was 0.16 ± 0.11 mmol/l . Δ[Glu] was -0.19 ± 0.31 mmol/l, which was not significantly different from zero, with SVC [Glu] being less than IVC [Glu].There were no differences in SO2 and Δ[Lac] in hemodynamically stable individuals with pulmonary artery hypertension. An alternate mechanism is mixing with coronary sinus blood, implying that ΔSO2 and Δ[Lac] may reflect changes in coronary sinus SO2 and [Lac] in this patient population.Mixing of SVC with IVC blood does not account for the development of ΔSO The YSI 2300 STAT Plus measures [Lac] and [Glu] in whole blood and has been used in studies of blood [Lac] in critically ill individuals [10.11]. The accuracy of whole blood lactate measurements, as compared with those in plasma, was previously established , and 0.21 mmol/L for [Glu].Blood samples were immediately placed in ice and promptly analyzed in triplicate  for SO2 ablished . The repablished  with the2, [Lac], and [Glu] at each sampling site. The Tukey HSD test [P < 0.05 denoting a statistically significant difference.Analysis of variance for repeated measures was used to compare mean SOHSD test  was perf2 and [Lac] measured at each sampling site, and Figure 2 and [Lac]. There were no differences in SO2 between IVC and SVC. SO2 levels at the IVC and SVC were greater than that at the pulmonary artery (P < 0.01) and were greater than SO2 at the right atrium and right ventricle sites (P < 0.01 for IVC and P < 0.05 for SVC). There were no differences in SO2 among right atrium, right ventricle, and pulmonary artery sites. ΔSO2 was 4.4 ± 1.4%, which was significantly different from zero (P < 0.001).Table P < 0.01 for IVC and P < 0.05 for SVC). IVC [Lac] was also greater than right atrial and right ventricular [Lac]. There were no differences in [Lac] among right atrium, right ventricle and pulmonary artery sites. Δ[Lac] was 0.16 ± 0.11 mmol/l, which was significantly different from zero (P < 0.001).There were no differences in [Lac] between the IVC and SVC sites. IVC [Lac] and SVC [Lac] were greater than pulmonary arterial [Lac] . There were no differences in [Glu] among the IVC, right atrium, right ventricle, and pulmonary artery sites. Δ[Glu] was -0.19 ± 0.31 mmol/l, which was not significantly different from zero.Figure 2 and [Lac] gradients from SVC to pulmonary artery is mixing of SVC with IVC blood. To that end, we measured the steady state concentration of oxygen and [Lac] in the central veins, the right heart chambers, and the pulmonary artery in hemodynamically stable individuals who were suspected of having elevated pulmonary artery pressures.The aim of the present study was to test the hypothesis that the mechanism responsible for the development of SO2 in SVC with that in the pulmonary artery. The majority of these studies found decreases in SO2 as blood travels from SVC to pulmonary artery. The average ΔSO2 of 4.4% found in the present study agrees with mean values of 3% to 5% reported by others. According to our results, however, mixing of SVC with IVC blood cannot account for the development of ΔSO2 and Δ[Lac], as noted in this patient population. The average concentrations of oxygen and lactate in SVC and IVC blood were indistinguishable from each other. Moreover, SO2 and [Lac] in the SVC and IVC were both greater than the respective pulmonary artery values. Therefore, it would be physically impossible for the mixing of SVC and IVC blood streams to produce pulmonary artery blood of lesser SO2 and [Lac].Several studies -3,15-26 2 (mean SO2 = [IVC SO2 + SVC SO2]/2) provides a first order estimate of right atrial SO2. Assuming no input whatever from other venous sources, such as coronary sinus, the estimate for right atrial SO2 computed in this manner should equal pulmonary arterial SO2. Table 2 and pulmonary arterial SO2 reported in published studies measuring SO2 in the central veins, the right heart, and pulmonary artery in humans  in the central vasculature, and only two other studies have compared lactate concentrations in SVC and pulmonary artery. Weil and coworkers  found no2 and [Lac] in IVC and SVC than in pulmonary artery indicates that further dilution of oxygen and [Lac] takes place as blood flows through the right heart chambers. Given the vigorous myocardial extraction of oxygen and lactate, venous concentrations of those chemical species are lowest in coronary venous blood, which includes blood emanating from coronary sinus and the Thebesian system. Therefore, it is possible that blood flowing from the coronary sinus and Thebesian veins exerted a small but measurable diluting effect on right atrial SO2 and right atrial [Lac]. We lacked direct samples of coronary venous blood and cannot prove this hypothesis conclusively from the data presented. Lending support this notion, however, are the observations that significant decreases in SO2 and [Lac] occurred mainly in the right atrium, which is the anatomical location of the coronary sinus (Figure The finding of greater SOs Figure .2 and [Lac]. SVC [Glu] was lower than IVC [Glu], reflecting the high rate of cerebral glucose uptake. In adult humans glucose represents the main, if not the sole, substrate of brain energy metabolism, with the brain utilizing approximately 25% of circulating blood glucose [2 and [Lac], right atrial [Glu] was greater than SVC [Glu] but nearly equal to IVC [Glu]. This concentration distribution is that expected for a metabolite whose coronary sinus concentration approximates that of SVC blood, such as may be the case for glucose in fully aerobic conditions [We found that the distribution pattern for [Glu] differed from those of SO glucose ,37. In cnditions .The individuals studied had elevated pulmonary arterial pressures, and patients with pulmonary arterial hypertension frequently have right-sided valvular regurgitation, right ventricular dilatation, and right-to-left shunts through a patent foramen ovale. Angiography did not reveal patent foramina or septal defects in any of the patients included in this study. Given their moderate severity of pulmonary arterial hypertension, right ventricular dilatation and pulmonary and tricuspid regurgitation in this particular group of patients were likely to have been modest. On the other hand, it is conceivable that retrograde transvalvular flow through the pulmonary valve could have affected right ventricular and pulmonary arterial values. Samples were obtained sequentially, not simultaneously, and the possibility exists that temporal changes in concentration occurred in the different sampling sites as the catheter was advanced into the pulmonary artery. To avoid this possibility, care was taken to verify with fluoroscopy the position of the catheter at each sampling site and the blood sampling procedure was performed within a span of 5 min, with no changes noted in heart rate or blood pressure in any of the patients. Finally, Δ[Lac] and Δ[Glu] were small when compared with the precision of the measuring instrument. This raises an important question regarding the utility of single measurements of Δ[Lac] and Δ[Glu], a question that only can be answered by further clinical studies.2 and Δ[Lac] in the patient population studied cannot be explained by the mixing of SVC and IVC blood. The development of these gradients appears to require mixing with blood of lower SO2 and [Lac], most likely blood emanating from the coronary sinus and Thebesian veins. Because coronary venous blood SO2 and [Lac] vary according to the rates of oxygen and lactate utilization by the heart, this mechanism suggests a possible role for ΔSO2 and Δ[Lac] as markers of myocardial energy metabolism in hemodynamically stable individuals [The development of ΔSOividuals . Furtherividuals .2 and [Lac] gradients exist from SVC to pulmonary artery.• Blood SO• These gradients were not produced by mixing of SVC blood with IVC blood in a population of patients with mild-to-moderate pulmonary hypertension.2 and [Lac] were noted to be greatest in the right atrium, suggesting that mixing of SVC with coronary venous blood is the primary mechanism resulting in ΔSO2 and Δ[Lac].• Decreases in SO2 and [Lac] vary according to their rates of utilization by the heart, and so it may be possible for ΔSO2 and Δ[Lac] to serve as markers of myocardial energy metabolism in the patient population studied.• Coronary venous blood SO2 = oxygen saturation; SVC = superior vena cava.[Glu] = glucose concentration; IVC = inferior vena cava; [Lac] = lactate concentration; SOGG has served in the past as consultant to Hospira, Inc., a manufacturer of pulmonary artery catheters. Hospira Inc. was not involved in any aspect of the study. GG holds a patent on a method related to the subject matter of the study. None of the other authors declare any competing interests.GG conceived and designed the study, analyzed, interpreted the data and wrote and reviewed the manuscript. AV acquired data and reviewed the manuscript. EI designed the study, acquired data, and reviewed the manuscript. JR acquired data, and reviewed the manuscript. LC designed the study, and reviewed the manuscript. AD designed the study, acquired data, and wrote and reviewed the manuscript.


Practitioners in the Veterans Health Administration (VHA) identified comprehensive weight management as a high priority in early 2001.MOVE! Weight-Management Program for Veterans was developed on the basis of published guidelines from the National Institutes of Health and other organizations. Testing of program feasibility occurred at 17 VHA sites, and the program was refined during early implementation throughout 2005.The MOVE! has been implemented at nearly all VHA medical centers. By June 2008, more than 100,000 patients had participated in MOVE! during more than 500,000 visits. An evaluation based on an established framework is under way.MOVE! is an example of the large-scale translation of research into practice. It has the potential to reduce the burden of disease from obesity and related conditions. Overweight and obesity are tremendous health problems for the US population. Recent national prevalence estimates indicate that 66.3% of adults are overweight or obese . SimilarAddressing the problem of overweight and obesity in the VHA system is complex. The VHA is the nation's largest integrated health care system; it operated 155 medical centers and 872 community and outpatient clinics in 2006. During that year, the VHA served 5.5 million patients and registered more than 60 million visits within its outpatient clinics  began to develop an evidence-based weight-management program for patients seen at VHA medical facilities. The program incorporated elements essential for gaining support within a large health care system, including an informational letter and other communications to describe for leaders and field-based clinicians the need for such a program and to keep stakeholders aware of the program's development.MOVE! (Managing Overweight/Obesity for Veterans Everywhere) Weight-Management Program for Veterans (www.move.va.gov) was created on the basis of guidelines from the National Institutes of Health (NIH) (The th (NIH) ,9 and otth (NIH) .MOVE! is a clinical process and set of tools for facilities and clinicians to offer an evidence-based, multidisciplinary, comprehensive approach to weight management that is centered around the patient and tailored to individual needs. All patients seen in primary care clinics are screened at least every 2 years for overweight and obesity using body mass index (BMI). Patients who would benefit from MOVE!  are assessed for the appropriateness of recommended weight loss . Patients who indicate readiness to attempt weight loss are offered participation in MOVE!. Core treatment uses established behavior change and self-management strategies for diet and physical activity change.Designed to be integrated into patients' ongoing care and implemented in primary care clinics, MOVE! by completing a paper or Web-based 23-item baseline assessment, the MOVE!23 questionnaire (www.move.va.gov/Move23.asp). This assessment elicits information about medical history; weight and weight-management history; motivational factors; barriers to modifying physical activity, diet, and weight-related behaviors and patients' readiness to change these behaviors. On completion, patients receive a summary report that identifies their individual needs and recommendations, supplemented by tailored links to specific patient handouts. More than 100 handouts about nutrition, physical activity, and behavior change are available in English and Spanish on the MOVE! Web site (www.move.va.gov/handouts.asp). The handouts are given to patients by staff or downloaded by patients. The program also produces a staff version of each patient's report, identifying key medical and counseling issues, and automatically enters both the patient and staff reports into the patient's electronic VHA medical record.Patients begin participation in MOVE!23 report with the patient, staff assist the patient with setting 1 to 3 specific short-term nutrition, physical activity, or behavior change goals. Staff provide diet and physical activity logs and may give pedometers to patients to track steps. Staff follow up with patients by telephone or in person in 1 to 3 weeks to determine progress toward or barriers to meeting goals. Ideally, staff-patient contact is ongoing, based on continuing patient need and desire for supported self-management. Many patients also attend group sessions for further instruction and support. Modules for multidisciplinary staff to use in conducting group sessions (www.move.va.gov/GrpSessions.asp) have been developed as part of MOVE!. Individual consultation is available for patients who need tailored treatment plans because of comorbid illness or other complicating factors. For patients who need more intensive interventions, Veterans Affairs (VA) facilities provide on a limited basis weight-loss medications, intensive medical management, and bariatric surgery.After reviewing the After initial program materials were developed, 17 VHA medical facilities volunteered to participate in pilot feasibility trials between October 2003 and December 2004. Each facility obtained local institutional review board approval and implemented the program using the materials provided — modified to suit local considerations — enrolling 30 to 70 patients for 6 months. To mimic real-world conditions, no additional staff resources or funds were given to sites. Staff and patients evaluated the materials and program for usability and suitability by using surveys, and staff provided feedback during conference calls; overall ratings were positive. Materials were revised and improved in response to staff and patient feedback. The VA Weight Management Executive Council, composed of nationally recognized experts in weight management, nutrition, and physical activity, provided review to aid development. On the basis of pilot results, the council endorsed the program as a state-of-the-art population-based weight-management initiative.The VA Under Secretary for Health strongly supported the program during all phases of development and system-wide implementation. NCP staff made many presentations at internal VA meetings and external professional meetings. These influences heightened awareness and strengthened demand for the program among clinicians in the field.MOVE! at their facilities in 2005. During this time, regular conference calls between NCP and staff at these facilities created a forum for sharing successes and challenges related to program implementation and provided an opportunity for input for further program refinements.Several early adopting medical centers and networks began to fully implement MOVE! was implemented nationally in January 2006. That month, NCP sent all networks and medical centers a toolkit with starter sets of patient handouts, promotional brochures, clinical references, and administrative manuals (www.move.va.gov/ReferenceTools.asp), as well as marketing materials . Online discipline-specific training modules about weight management with continuing education credit available for physicians, nurses, dietitians, behavioral health specialists, and physical activity specialists were also released.MOVE! as a model for complying with the new policy  issued a joint  Obesity . From 20MOVE! using the RE-AIM framework, developed by Glasgow et al .NCP is conducting a comprehensive mixed-methods evaluation of ow et al . This moMOVE! programs in place. Patient participation has steadily increased over time  facilities now report having ver time . CurrentMOVE!.Data collected by the VHA's performance measurement system during 2008 indicate that 66% of primary care patients have been screened for obesity. To date, of patients who would benefit from weight management based on BMI, health status, and absence of contraindications, 7.5% have participated in Challenges to this evaluation include the many local modifications to program delivery, which facilitates adoption but introduces heterogeneity, making quantitative analysis difficult. However, with implementation variability comes an opportunity to identify best practices and key elements associated with more effective programs. Clinical data  extracted from the VHA electronic medical record have not been available nationally until recently, and more validation work is required to be able to accurately interpret these data.MOVE! Weight-Management Program has potential for providing evidence-based, comprehensive weight management to the more than 4 million veterans enrolled in VHA health care who are at risk for obesity-related conditions. Created on the basis of a systematic NIH evidence review and designed to be an intensive model of care, as recommended by the US Preventive Services Task Force, MOVE! provides an extensive set of program materials for staff and patients to assist with long-term weight management. VHA medical facilities can incorporate this treatment model into local settings in ways that best facilitate their adoption.The VHA's MOVE! tools that have been developed, which will extend the reach of MOVE! to active duty members and their families. In 2007, the DoD Weight Management and Education Workgroup was charged with developing an evidence-based program of care that could be implemented in DoD medical treatment facilities and has adopted MOVE! as the standard weight-management program if weight-management programs are not in place.Through their collaborative work , VA and MOVE! for patients, some facilities began to use MOVE! materials and procedures for the benefit of VA employees. A MOVEmployee! manual, describing alternative ways to implement these services, was added to the program materials in 2006. As of late 2007, 63 employee programs existed.The program has also been extended to VA employees. Soon after implementing MOVE! has been through the HealthierUS Veterans initiative, a collaboration between the VA and Department of Health and Human Services (MOVE! resources, including the MOVE!23 and patient handouts, outside of the VHA. Veterans and family members may complete the assessment, print out both the individual and staff reports and associated handouts, and take them to their non-VHA medical providers.Another opportunity to extend the reach of Services . HealthiMOVE! implementation has helped to raise the profile of obesity research within the VHA community. A number of VA- and NIH-funded studies have been completed or are in progress and include an investigation of changes in obesity care practices within VHA; a study comparing enhanced physical activity interventions with MOVE!; studies adapting MOVE! materials for special populations, including veterans with serious mental illness and veterans with spinal cord injuries or disease; a study of the long-term outcomes of bariatric surgery within the VHA; and a study evaluating 2 enhancements to usual MOVE!-tailored patient newsletters and peer-led self-management support.MOVE!. Many veterans live at considerable distances from VHA medical centers or community clinics, so plans include enhancing Web-based tools to be more interactive. VHA has an extensive program for home telehealth management of chronic diseases, such as diabetes and heart failure. Development of a MOVE! telehealth program for overweight and obese patients with metabolic syndrome or prediabetes is under way. This program will encourage patients to weigh themselves frequently and use a simple electronic device to report eating and physical activity patterns. Using the device will provide encouragement and support for patients who meet their goals and will alert staff when monitored parameters become out of range. To facilitate ongoing telephone contact between patients and staff for self-management support, plans for regional call centers with health coaches are being developed.The NCP continues to develop and refine MOVE! Weight-Management Program for Veterans is an innovative and comprehensive strategy to provide sophisticated treatment for overweight and obesity to veterans. The program also provides an opportunity to study the best strategies for delivering this care and for measuring the health outcomes of patients who receive it. Similar to VHA's implementation of quality improvement and system change for tobacco control (MOVE! is an example of translation of research and evidence-based medicine into broad medical practice in a large health care organization.The VA's  control , MOVE! iMOVE! resources was provided by Roche through an unrestricted educational grant to the VA. All other funding has been provided by the VA. The views expressed in this article are those of the authors and do not necessarily represent the views of the VA.Partial funding for initial development of


Lymphatic filariasis (LF) is a disfiguring and debilitating parasitic disease that is endemic in 81 countries, placing a staggering 1.3 billion people at risk for filarial infection Although significant progress has been made since the inception of GPELF, there are still many challenges that stand in the way of success. At the onset of the global program, the recommended strategy was to administer annual MDA for four to six years. At that time, this recommendation was thought to be sufficient for interrupting transmission. As the program has progressed, it has become increasingly evident that although transmission appears to have been interrupted in some areas after only five rounds of MDA, this has not been the case in other places Haiti represents approximately 78% Although the national program didn't begin until 2001, a pilot mass treatment program began in Leogane the previous year. The commune of Leogane comprises both urban and rural zones and is located approximately 30 km west of Port au Prince, with an estimated population of 150,000. Before intervention, antigenemia in this area was approximately 50% After five rounds of MDA (2000–2005), antigen prevalence had decreased significantly, from nearly 50% to 15%. There was also a significant reduction in microfilaremia from 15% to <1% p<0.001) in prevalence from 2005, consistent with ongoing transmission in the area (In 2007, antigen prevalence in Leogane town and Masson-Mathieu was 31.2% and 14.5%, respectively. Both findings represented significant increases (the area . The resThis limited example from Haiti begins to give insight into the consequences of missed MDAs and has broader implications for the global program. The potential for recrudescence of antigenemia is an obvious setback to national programs, and the Haitian experience has shown that there can be a significant loss of investment if programs are not sustained. In highly endemic settings such as Haiti, a funding gap can inadvertently introduce additional obstacles in an already challenging programmatic situation. There are also less obvious issues that must be considered. Inconsistent drug delivery could lead to confusion and fatigue within the communities as the necessary rounds of MDA are prolonged over additional years. These inconsistencies could result in a loss of credibility for the LF programs and ultimately lead to a decline in political commitment and support, a critical determinant of the success of programs With so many challenges facing LF programs, there must be an effort to stabilize annual rounds of MDA as much as possible. Achieving this stability requires sustained political and social commitment, careful planning to ensure adequate drug supply, and consistent funding. In stable political and funding climates, programs can optimize opportunities to achieve success. Perhaps the setback observed in Haiti was a result of a strategic error in the initial decision to focus on high-prevalence communes that were scattered geographically. Treatment in these areas may have led to a decrease in antigen prevalence, but the potential contribution of adjacent areas to ongoing transmission was not considered. In retrospect, it is difficult to know whether treating an entire geographical region would have been a better use of the limited resources. However, this does not obviate the need for continued, sustained funding in any case, possibly for a longer period than originally anticipated. Finances remain the greatest barrier to the expansion of LF programs, and limited resources are the reality of the day. However, strengthening partnerships can potentially maximize the use of scarce resources and promote financial stability. With extensive geographical overlap of neglected tropical diseases, there is great opportunity to link control programs and achieve program synergy