SARAH LINKE
University of California San Diego

Insufficient physical activity (PA) is a leading risk factor for most chronic health conditions. Identifying patients at higher risk of these conditions due to their insufficient levels of PA is one of the highest priorities given the evidence suggesting that insufficient PA poses as much of a risk to patients’ health as other established risk factors that are routinely addressed within the primary care setting (e.g., smoking, hypertension, obesity) and creates a significant financial burden on the healthcare system. Numerous interventions effectively increase PA, but few are integrated into primary care clinic workflows. Exercise is Medicine (EIM) is a global health initiative committed to the belief that PA is integral to the prevention and treatment of diseases and should be routinely assessed as a vital sign and treated in the healthcare setting.

This paper describes an in-progress embedded quality improvement (QI) project that integrates EIM into routine clinical practice. A combination of implementation science (IS) and QI models are used to adapt, implement, and evaluate the integration of EIM into six primary care clinics on a rolling basis.

The Practical, Robust Implementation and Sustainability Model (PRISM) guided pre-implementation evaluation and adaptation of EIM protocol, materials, and delivery strategies. The Learning Evaluation QI model is used to design, test, refine, and implement EIM using rapid, 3-month Plan Do Study Act micro-cycles. The Stirman Framework is used to document adaptations to the program throughout implementation. Reach, adoption, implementation, effectiveness, and maintenance (RE-AIM) outcomes embedded within PRISM are used to guide the program evaluation to determine sustainability and scalability. Data is obtained through the electronic medical record (EMR) and periodic patient surveys.

In terms of adoption and reach, a total of 38,899 PAVS (Physical Activity Vital Sign) self-reported questionnaires have been recorded in the EMR, representing a total of 17,275 unique patients, which translated to 35%, 43%, 82, and 87% of all patients seen in each of the four clinics (integrated on a rolling basis). Implementation of the different program components (screening, diagnosis, PCP discussion, documentation, prescription, and optional health coaching) has been high with the exception of documentation. Patients recalled discussing PA with their PCPs and/or receiving information about exercise in 73% of visits. Effectiveness and maintenance will be evaluated in the next 3 years. Discussion: Using an innovative approach of combining IS and QI methods to improve the identification of primary care patients with insufficient PA to increase their activity levels has great population health potential. Our work will inform best approaches for EIM integration in primary care.

HANNAH G. LANE
Duke University

Evidence-based initiatives that promote wellness (e.g., healthy food access, physical activity, and social emotional well-being) during school are critical to improve child health and reduce inequities. Such initiatives are not always prioritized for a range of reasons, including implementation context. This explanatory mixed methods study explores how having a “climate for wellness” influences implementation of wellness initiatives in schools.

Elementary schools participating in a national mixed methods surveillance study of wellness policy implementation. The purposeful qualitative sample of schools (n=39; 19 urban, 20 rural) is nested within the quantitative sample (n=521). In total, 50 informants (20 principals, 9 physical education teachers, 21 other staff; 80% female) participated in interviews.

An informant from each school completed a survey during the 2019-2020 school year to investigate determinants of and strategies used to implement wellness initiatives, including 6 climate items (?=.90) adapted from the from the Wellness Readiness Assessment Tool (scored on a 3-point Likert scale, max score=12). Informants from rural and urban schools were invited to participate in semi-structured interviews informed by the Consolidated Framework for Implementation Research. Interviews explored schools’ implementation climate by investigating inner setting factors of culture, communication networks, external policy/pressure, leadership engagement, relative priority, social capital, and tension for change. For mixed methods analysis, climate scores were summed then dichotomized into higher (>6) or lower (<6) climate. Qualitative comparative analysis was used to identify discrepant themes between high and low climate schools.

In the full sample, schools were 28.6% rural, 13.8% town, 20.9%urban, and 36.7% suburban. Over half (60.3%) had higher climate scores, 39.7% had lower scores (Mean=7.4; SD=3.3; range=0-12). In the qualitative sample, 24 (61.5%) had higher climate scores and 15 (38.5%) had lower scores (Mean=8.0; SD=3.2; range=2-12). Across all schools, the overlapping presence of a “culture of wellness,” explicit support from leadership, and communication networks that included families aided implementation of wellness initiatives. Discrepant themes among lower climate schools included: limited engagement of parents and community members in wellness-promoting culture, wellness initiatives driven by a few champions rather than a school-wide effort, and misalignment of the priorities of school leaders and teachers, staff and parents.

Practical and relevant implementation strategies that are tailored to schools’ baseline climate for wellness are needed. Strategies should address gaps at the intersection of culture, leadership and communication. Future research is needed to empirically investigate the influence of climate on wellness implementation processes and outcomes.

QING LI, MD, DrPH
Colorado School of Public Health

Perinatal intimate partner violence (IPV) is a common but unresolved barrier to achieving preventive effects of early home visiting. Two randomized controlled trials (RCTs) of the Nurse Family Partnership (NFP) program augmented with IPV components did not achieve a reduction in IPV or improvement in maternal quality of life. One reason may be that women do not often disclose IPV experience and care providers face challenges, especially among minority women. Latinx mothers are particularly vulnerable due to reproductive coercion and machismo. Furthermore, immigrant Latinx face barriers (e.g., fear of deportation). However, the IPV prevention effects and nativity differentiation among Latinx mothers have not been analyzed.

In secondary data analyses of one RCT, first-time, low-income mothers were recruited and randomly assigned to the standard or augmented programs of NFP in Multnomah County, Oregon from 2007 to 2011. Among the 238 women completed the baseline survey, retention was 88% and 81% at 1-year and 2-year follow-ups. Among 119 Latinx mothers at baseline, the augmented (n=75) and standard (n=44) program participants were stratified into the U.S.-born (n=33) or foreign-born (n=86) status.

Nurses were trained and delivered the adapted Within My Reach Curriculum to prevent IPV. The sum of any type of physical and sexual victimization and/or perpetration in the past 12 months in the Revised Conflict Tactics Scale was coded as an ordinal outcome from 0 (none) to 4 (types) and measured across 3 time points. We performed the proportional odds model of generalized estimating equations to investigate the association between nativity and IPV, adjusting for the intervention status and covariates such as age.

Foreign-born Latinx mothers were more likely to have lower education and low family yearly income ( <$21,000), but more likely to be employed, older, and older at first sexual intercourse, report being married or engaged, and IPV free or low violence types (p<0.05). Adjusting for maternal age, the visit-intervention and visit-nativity interactions were dropped from the model due to no significance. In the final model, the intervention program and foreign-born status were significantly associated with less IPV types 2 year later [Adjusted Odds Ratio (AOR): 0.57, 95%Confidence Interval (CI): 0.34 to 0.97, p=0.038; AOR: 0.47, 95% CI: 0.27 to 0.83, p=0.009). One-year increase in age at the baseline was marginally associated with less IPV types (AOR: 0.95, 95% CI: 0.90 to 1.01, p=0.081).

Preliminary findings show that the augmented NFP program prevented IPV among Latinx mothers, especial foreign-born and older ones. Culturally tailored curricula can better detect and prevent IPV and optimize the resources for health equity. Evidence re-analyzed from this RCT and further needs assessment can inform the design of cultural-tailored programs to prevent IPV among Latinx families.