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Be mindful—be well: a randomized comparative effectiveness trial—addressing brain health among older African Africans

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Be mindful—be well: a randomized comparative effectiveness trial—addressing brain health among older African Africans

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Content Running Head: BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE 1
EFFECTIVENESS TRIAL

BE MINDFUL-BE WELL: A Randomized Comparative Effectiveness Trial
Addressing Brain Health Among Older African Africans
Doctorate in Social Work Capstone Proposal
Bryan F. Gaines
University of Southern California

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 2

© 2018 Bryan F. Gaines

Recommended Citation:
Gaines, B. F. (2018). BE MINDFUL-BE WELL: A Randomized Comparative Effectiveness Trial-
Addressing Brain Health Among Older African Africans. University of Southern California,
Suzanne Dworak-Peck School of Social Work: Doctorate in Social Work Capstone Proposal.
Los Angeles, California.
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 3

Dedication
I would first like to thank God for guiding my life and giving me strength to let no
weapons formed against me—prosper. My promise to God is to use the gifts He has bestowed
upon me to make the world a better place for all. Through His grace and mercy, I Rise.
A special dedication to my amazing mother and grandmother that supported me
throughout my life challenges with every measure of unconditional love. To my family, thank
you for showing patience and understanding while graduate school kept me extremely busy and
missing family gatherings. I am forever grateful for all the love and support. Many Blessings.

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 4

Acknowledgments
In honor of Melvin Gaines (deceased), my father (see Appendix A for more information
about my father’s story), who was diagnosed in 2004 with Alzheimer’s disease (AD), I dedicate
this work to him and acknowledge the millions of families at risk for or struggling with AD. A
special thanks to my mother, Mardell M. Reed and my grandmother, Yvonne A. Shelton
(deceased) for their endless love, support and dedication throughout the years. I would also like
to thank my friend, mentor, and supervisor, Dr. Karen Lincoln, Associate Professor, USC
Suzanne Dworak-Peck School of Social Work—for her guidance, support, and dedication. A
special thanks to USC Roybal Institute on Aging for generously supporting the work of
Advocates for African American Elders (AAAE). Special recognition to my senior mentors that
took me under their wings, and to the volunteers, interns, and senior advisory members that give
of their time—sharing their expertise—making this work possible.
A very special thanks to local senior centers, senior housing, health care systems, social
clubs, churches, senior social service agencies, and older community-dwelling African
Americans for their support and engagement with AAAE for the past six years. Additionally,
serving the community through community-based participatory research would not have been
possible without the generosity of the California Wellness Foundation, SCAN Foundation, USC
Keck School of Medicine-Alzheimer’s Disease Research Center (ADRC), Clinical and
Translational Science Institute (CTSI), Gerontological Society of America (GSA), and local
health plans.
Finally, special thanks to the organizations serving families impacted by AD—for decades. A
gracious recognition to Congresswoman Maxine Waters for her endless support and advocacy
for funding AD research at the federal level through the National Institute of Health (NIH).
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 5

BE MINDFUL-BE WELL: A Randomized Comparative Effectiveness Trial
Addressing Brain Health Among Older African Africans
Alzheimer’s disease (AD)—a serious public health problem in the United States (U.S.),
with an estimated 5.7 million Americans living with AD or a related dementia and by 2050
(Alzheimer’s Association, 2018), this number could rise as high as 16 million (Hebert, Weuve,
Scherr, & Evans, 2013). AD is the fifth-leading cause of death among adults age 65 to 85 years,
is a leading cause of disability and poor health, and is the only disease in the top ten causes of
death that cannot be prevented, cured or even slowed (Alzheimer’s Association, 2017).
Traditionally, the U.S. has relied on treating illness using a medical model that has led to gaps in
health care, failed practice and poor health outcomes (Browne, Gehlert, Andrews, Zebrack,
Walther, Steketee, & Merighi, 2017)— rather than more promising prevention and or risk
reduction models. This Capstone Proposal will provide a summary of the proposed pilot project,
conceptual framework, statement of solution, methodology, implication to practice, and future
decisions and actions.
Executive Summary
According to Newman and colleagues (2015), “Closing the Health Gap Grand Challenge
of Social Work aims to address the inequities in health and the devastating impact on millions of
Americans’ facing chronic health conditions in addition to economic, social, and environmental
factors that determine health outcomes” (p. ii127). The AD disparities among older African
Americans (AAs) are related to a cycle of health inequities that have led to poor health
outcomes. The promising practices of Disruptive Innovation is increasingly becoming a tool used
by leaders to advance ideas, question the status quo, make associations, experiment, network,
and observe current practices (Dyer, Gergesene, & Christensen, 2011) by engaging health care
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 6

systems in such practices increases opportunities for closing the gap in health care, achieving
more equitable health care outcomes, and a pathway to social justice.
To address the specific problem, Advocates for African American Elders (AAAE) (see
Appendix B), under the auspices of USC Suzanne Dworak-Peck School of Social Work will be
the lead research team in charge of implementation and delivery of the proposed pilot project
titled BE MINDFUL-BE WELL—a 1-year pilot project aimed to examine current practices of
brain health/AD “usual care” (e.g. basic AD printed materials), targeting AAs age 45 and older
and their caregiving networks. The pilot is designed to integrate and implement brain health &
AD literacy, and awareness of physical activity & health-protective behaviors within the nation’s
largest publicly operated existing health care system, LA Care Health Plan (LA Care).
Specific aims are to determine whether, BE MINDFUL-BE WELL—a tailored brain
health education program and workshop is more effective for increasing brain health/AD
knowledge and literacy vs. “usual care”, and to determine whether BE MINDFUL-BE WELL
enhanced with a 6-week BE MINDFUL-BE WELL BRAIN HEALTH CHAMPION BOOTCAMP
targeting AAs is more effective for increasing brain health/AD knowledge and literacy and
improved health and physical activity vs. “usual care” that could potentially serve as a brain
health risk reduction model for health care systems across the nation.
Long-established approaches to brain health/AD education, including the reliance on
print communication, local community presentations, and other technology, are inadequate given
the population’s low literacy levels, lack of internet use, and adopting new technologies
(Lincoln, et al., in press). Despite evidence linking low literacy to heightened AD risk (Kaup,
Simonsick, Harris, Satterfield, Metti, Ayonayon, & Yaffe, 2014; Lincoln, Chow, & Gaines, in
press), AD literacy programs have failed to integrate systems of care that serve AAs or other
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 7

high-risk, high-cost populations—at greater risk for developing AD or a related dementia. Lack
of brain health/AD education sources for AAs results in crisis for patients, caregivers, and
healthcare systems that serve them. Patients typically seek care during crisis, with miminal
options or access to care, treatment, and social support (Lincoln, et al., in press).
Results from this pilot study potentially will result in a new risk-reduction method for
addressing AD disparities among AAs. Increasing brain health/AD literacy among AAs is crucial
to increasing awareness of their personal AD risk, optimizing care, reducing disparities and
health-related costs, and ultimately enhancing the quality of life of people at risk and their
caregiving networks.
We hypothesize that brain health/AD knowledge and health literacy will increase, patient
and primary care physician communication will increase, overall health will improve, and
physical activity will improve because of attending a two-hour BE MINDFUL-BE WELL Talk
Show/Resource & Information Session—using Healthy Brain Initiative (HBI) curriculum from
the Alzheimer’s Association Demonstration Project, and attending a 6-week BE MINDFUL-BE
WELL- BRAIN HEALTH CHAMPION BOOT CAMP- a modified version of the 4-month “BE
WELL” program—a nutrition and exercise program designed for high risk older adults.
Measures include: pre-screen measures for inclusion in study—Folstein Mini-Mental
Status Exam (MMSE)—a practical method for grading the cognitive state of patients, pre- brain
health survey that includes: demographic information (i.e. gender, race, ethnicity, age, marital
status), Alzheimer’s Disease Knowledge Scale (ADKS), and Short-Test of Functional Health
Literacy (S-TOFHLA). Boot camp measurements—measured at base line, program completion
at 6-weeks, and at 6-month following (optional) maintenance program. Blood pressure, body fat,
weight, and Body Mass Index (BMI) are measured weekly. Additional measures include,
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Nutrition Risk Assessment, Depression Assessment PHQ-9, Activities of Daily Living (ADLs)
Questionnaire, The Lawton Instrumental Activities of Daily Living (IADLs) scale, and fitness
tests. Finally, we will administer post measures and overall satisfaction surveys for participation.
This capstone proposal is innovative by design—aimed to disrupt “usual care” within an
existing health care system to provide new evidence that addresses the impact and effectiveness
of a risk-reduction model that could potentially be implemented within existing health care
systems to address populations at greatest risk for developing AD—through the promotion of
brain health.
Conceptual Framework
Americans’ are considered the least healthy—in one of the wealthiest countries— in
comparison to other peer countries (Institute of Medicine, 2013). Hence, the Grand Challenge of
Social Work—Closing the Health Gap has been established to address health disparities. This
Grand Challenge Capstone addresses the link between poor health outcome categories in the
United States (U.S.) and risk factors for AD or a related dementia—examining AD risk-
reduction through the promotion of brain health awareness and health-protective behavioral
lifestyle changes (e.g. physical activity, healthy eating, sleep, etc.).
In 2013, the National Institute of Health (NIH) published the United States Health in
International Perspective: Shorter Lives, Poorer Health, a report that examined the nature and
strength of research evidence for life expectancy and poor health outcomes; comparing U. S. data
with statistics from other wealthy countries using current data and historical trend data starting
from 1970, and statistics from 1990-2008. The report illustrates poorer health outcomes for
Americans’ in nine health categories (e.g. heart disease, HIV and AIDS, diabetes, obesity, etc.),
associated with both disadvantaged and advantaged populations (Institute of Medicine, 2013)
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with multiple likely explanations for health disadvantages in the U. S.—lack of universal health
care and health protective behaviors, social and economic conditions, and physical environments
(Institute of Medicine, 2013). Although not mentioned in the report—the Centers for Disease
Control and Prevention (CDC) project that AD will be the next epidemic and expect the cost of
care and treatment to diminish the American health care system unless new strategies are
examined and implemented to address the complexities associated with the disease, particularly
among minority populations (Centers for Disease Control and Prevention, 2015).
In 2017, AD and other dementias cost the nation $259 billion, by 2050 these costs could
rise as high as $1.1 trillion (Alzheimer’s Association, 2017). Age is the greatest risk factor for
developing AD—followed by chronic health conditions (Centers for Disease Control and
Prevention, 2015). The prevalence, human toll, and economic costs of AD is increasing as the
older adult population grows exponentially.
AD is now the fourth-leading cause of death among AAs over 65, yielding a two to three
times likelier risk for AD than Whites (Mayeda, Glymour, Quesenberry, & Whitmer, 2016) and
linked to chronic health conditions and poor health outcomes (e.g. high blood
pressure/cholesterol, diabetes, obesity, etc.) prevalent among AAs (Alzheimer’s Association,
2017). AAs present with AD at a younger onset than Whites and symptoms are more severe at
the onset of the disease (Manly, & Jacobs, 1999). Many AAs are diagnosed during later stages
and lack access to resources for treatment, care, and support (Manly, & Jacobs, 1999; Hurd,
Martorell, Delavande, Mullen, & Langa, 2013; Lincoln, et al., in press). Delayed and
underreported diagnoses of AD and related dementias are more prevalent among AAs than
Whites (Alzheimer’s Association, 2015). AAs often delay conversations regarding cognitive
decline with primary care physicians by at least seven years due to lack of recognizing signs and
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symptoms of AD and related dementias—belief that memory loss is normal aging
(Clark, Kutner, Goldstein, Peterson-Hazen, Garner, Zhang, et al., 2005; Lincoln, et al., in press).
According to new CDC data, AD deaths increased 99% among AAs compared to 55%
among all Americans’ and death rates increased in 2014 compared to 1999—among all groups
(Taylor, Greenlund, McGuire, Lu, Croft, 2017; Lincoln, et al., in press). There are also fewer
approved AD treatments and survival rates are lower among AAs than other racial/ethnic groups
(Helzner, et al., 2008; Mehta, et al., 2008; Lincoln, et al., in press).
Poor health outcomes and racial disparities could potentially be reduced by increasing
health literacy. Health literacy is “the degree to which an individual has the capacity to obtain,
communicate, process, and understand basic health information and services to make appropriate
health decisions” (U.S. Department of Health and Human Services, 2010). Low health literacy is
one of the social determinants of health associated with health disparities (U.S. Department of
Health and Human Services, 2013). One study reviewed reported that when literacy was
considered, the effects of AA race and education diminished by 32% to the point that they were
no longer significantly associated with health outcomes (Sentell & Halpin, 2006; Lincoln, et al.,
in press). Other studies show that health literacy interventions are especially effective among
racial/ethnic minority populations (Lincoln, et al., in press).
Meanwhile, significant barriers to AD literacy among AAs increase their risk for AD,
disease burden, poor quality of life, and mortality. Low literacy levels among AAs overall limit
their ability to understand the healthcare information presented to them, and therefore, limits
access to health promoting information. For example, only 2% of AAs have proficient literacy
levels, the lowest of any racial group in the U.S. (Kutner, M., Greenberg, E., Jin, Y., & Paulsen,
2006; Lincoln, et al., in press). Twenty-four percent of AAs have below basic literacy levels—
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compared to 9% of Whites (Lincoln, et al., in press). As mentioned, the reliance on print
communication, local community presentations, and other technology creates barriers for AAs.
The common awareness campaigns aimed to raise AD awareness rarely reaches communities at
greatest risk, disregard learning abilities, and lack the cultural competencies to address cultural
differences (Centers for Disease Control and Prevention, 2018).
As a result, there are substantial gaps in knowledge and perceptions about the
effectiveness of brain health/AD literacy interventions for AAs and other high-risk populations.
AD health literacy, the ability to learn signs and symptoms of AD or related dementias to make
informed health decisions when symptoms manifest, remains extremely low among AAs
(Carpenter, Balsis, Otilingam, Hanson, & Gatz, 2009; Lincoln, et al., in press). The few studies
that exist, indicate that AAs report significantly lower levels of basic knowledge about AD than
Whites, lower levels of perceived risk of AD, and access to fewer sources of information about
AD or related dementias (Connell, Roberts, McLaughlin, & Carpenter, 2009).
In 2012, the National Alzheimer’s Association and Centers for Disease Control &
Prevention (CDC) conducted a community-level demonstration project to promote brain health
for AAs. The demonstration project targeted AA baby boomers with risk reduction messages,
hosted workshops promoting behavioral lifestyle changes (e.g. exercise, diet and cognitive
stimulation) and better management of chronic health conditions, and focused on risk factors
associated with cognitive impairment. Findings from the study provided evidence for future
study efforts and demonstrated an increase in knowledge, awareness, and the intent to make
lifestyle health-protective behavioral changes to address lifelong health and brain health (Fuller,
Johnson-Turbes, Hall, & Osuji, 2012).
Continuing the efforts to increase brain health/AD and dementia literacy among AAs is
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crucial and a priority to addressing AD/dementia risk, optimizing care, reducing disparities, and
ultimately enhancing the quality of life of through the promotion of brain health. Brain health
education and cognitive screening are not typically offered to patients as part of providers’
programs and services, even among programs designed for older adults (e.g., Kaiser Permanente
Senior Health programs). A more well-informed community can challenge cultural
misconceptions of AD/dementia, detect first signs of dementia, and seek early treatment, thus
increasing opportunities to promote brain health and address poor health outcomes, and
ultimately alleviate gaps in health care systems.
LA Care is seeking opportunities to provide members with comprehensive health
information, and could benefit from evidence on the effectiveness of brain health/AD literacy
programming for minority populations as they bear the escalating costs of care for AD. LA Care
has expressed the need for culturally appropriate interventions for their members and will assist
with the integration of findings into the organization’s existing health education systems (see
Appendix C for letter of support).
The proposed study addresses critical gaps in current knowledge which can increase brain
health/AD literacy and, consequently, improve health outcomes important to patients, caregivers,
and their providers. Improving brain health/AD literacy increases key stakeholders’ ability to
access, understand and use information in ways that promote individual and community health.
Given the health and economic burden of AD and the projected rise in cases, there is a growing
need to raise awareness about brain health/AD, promote risk-reduction models, and improve
access to early diagnosis and interventions for affected patients and their caregivers. This is
especially the case for AAs that are an at-risk, high-cost, lower literate population that
experiences excess burden due to AD. Risk factors such as age and genes are nonmodifiable, but
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others like increasing brain health/AD literacy, lowering blood pressure and cholesterol levels,
increasing mental and physical activity, and managing diabetes can be modified via risk-
reduction awareness. There are also resulting benefits from improved brain health/AD literacy
such as health-protective behavior change, help-seeking, self-efficacy, and early detection.
Hence, the substantial mental, physical, and financial toll of AD on individuals, families,
communities, and the healthcare system could be significantly reduced if individuals had greater
access to risk-reduction programs aimed to improve brain health and overall health outcomes.
In 2013, the Institute of Medicine convened a group of health literacy experts, clinicians
and policymakers to review the current state of health literacy research and practice. Experts
recommended tailoring care processes to meet the information needs of various populations and
various health conditions (Hewitt & Hernandez, 2014; Lincoln, et al., in press). In addition, they
emphasized the importance of culturally appropriate education methods to prioritize health
literacy within daily practice. However, current health educational programs and national
awareness campaigns are generally based on what policy experts and educators think people
know, rather than based on the evidence of what people know. Interventions that focus on risk-
reduction, increasing knowledge of brain health/AD and understanding of related dementias are
needed to address current gaps in knowledge and practice echoed at the 2017 Alzheimer’s
Association International Conference (AAIC) in London.
After endless debates on the effectiveness of risk-reduction models to promote brain
health, findings were presented last year at the AAIC in London that provides evidence for the
effectiveness of risk-reduction models and future recommendations (see APPENDIX D for risk-
reduction model). According Dr. Maria Carrillo the National Alzheimer’s Association is
committed to the efforts of finding a cure for AD but will invest resources, time and energy that
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focuses on risk-reduction and the promotion of brain health.
The goal of this capstone proposal is to provide evidence for engaging older AAs in brain
health/AD education, cognitive stimulation, brain health-protective behaviors and physical
activity, produce preliminary data to support strategies and future funding, and potentially serve
as a brain health risk-reduction model for health care systems across the nation (see Appendix E
for project logic model).
Statement of Solution
The proposed innovative solution is a community-partnered collaborative aimed to
address the Grand Challenge of Social Work—Closing the Health Gap. The priorities for Social
Work’s Grand Challenge to Achieve Health Equity include 1) focus on settings to improve the
conditions of daily life 2) advance community empowerment for sustainable health 3) cultivate
innovation in primary care 4) promote full access to health care 5) generate research on social
determinants of health inequities 6) foster development of an inter-professional health workforce
and 7) stimulate multi-sectoral advocacy to promote health equity policies (Walters, K., Gehlert,
S. Uehara, E., & Smukler, M. 2015).
Specifically, we are interested in piloting a risk-reduction model within one of the largest
healthcare systems in Los Angeles County, L. A. Care. Through this collaborative led by AAAE,
we convened with L. A. Care and Food & Nutrition Management Services, Inc. to develop and
design BE MINDFUL-BE WELL, an interactive brain health program (see APPENDIX F for
project artifact) aimed to address risk factors associated with AD and related dementias among
older African Americans and their caregiving networks. This program specifically aims to
increase health-protective behaviors, patient and primary care physician communication, overall
health, and physical activity awareness to improve brain health. BE MINDFUL-BE WELL will
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offer culturally relevant brain health literature for participants, a two-hour Talk Show/Resource
& Information segments—using AAAEs Talk Show Model & modified Healthy Brain Initiative
(HBI) curriculum from the Alzheimer’s Association Demonstration Project, and a 6-week BE
MINDFUL-BE WELL BRAIN HEALTH CHAMPION BOOT CAMP—a modified version of the
4-month BE WELL program (see APPENDIX I), a nutrition and exercise program designed for
high risk adults designed by Food & Nutrition Management Services, Inc.
A “Talk Show” model developed by AAAE to deliver difficult curricula on assorted
topics (Chen, Lincoln, & Gaines, 2015) will be used to deliver the two-hour BE MINFUL-BE
WELL talk show. The effectiveness of this model is described in an Issue Brief titled Thinking
Outside the Box: Creative and Culturally Competent Outreach Strategies in Health Care
Transitions (Chen et al., 2015) (see Appendix G). We will use existing and modified brain health
literature and curriculum (see APPENDIX H for talk show curriculum) developed by the
National Alzheimer’s Association and Centers for Disease Control & Prevention from the
aforementioned African American community-level demonstration project used to promote brain
health.
The BE MINDFUL-BE WELL BRAIN HEALTH BOOT CAMP will use the modified 6-
week version of BE WELL (see APPENDIX I for 6-week prototype), which will include basic
measures to determine base line before participation and follow-up measures after participation
and two-hour weekly classes for six weeks that reinforces brain health literacy and AD risk and
focuses on physical activities, food and nutrition content and simple meal solutions (see
APPENDIX J for bootcamp curriculum). At the completion of the program participants attend
the Brain Health Champion Celebration to celebrate accomplishments, learn the fundamentals of
being a brain health champion, how to use the brain health champion toolkit (see APPENDIX
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K), and how to engage and spread the word throughout communities— promoting brain health.
Additionally, an optional maintenance program (see Appendix L for maintenance program) will
be offered to participants to maintain progress through our coaching and buddy system, weekly
sessions and exercise, six-month measurement follow-up, and a graduation.
Implementing this model at the nation’s largest publicly operated health plan serving
low-income diverse communities for over 20 years, could have huge implications for existing
health plans to address the gap in brain health literacy. According to Chief Medical Officer, Dr.
Katrina Miller, M.D., LA Care currently has over 15,000 members with both Medicare and
MediCal of which 58% are cognitively or mentally impaired and 55% have three or more
chronic health conditions (e.g. diabetes, hypertension, obesity etc.) (K. Miller, personal
communication, March 12, 2018).
For many decades, public health officials have been addressing chronic health conditions
and aware of how social determinants of health impact every stage of medical complexity in
minority communities; yet, community-based frameworks are rarely used among
researchers.This is part of the historic discriminatory laws and practices against African
Americans to have unequal access to basic needs including culturally relevant and appropriate
research practice. These injustices allow chronic diseases to persist and impact health outcomes
due to multiple competing needs unaddressed (see appendix M).
The proposed innovative solution is a targeted effort to disrupt current trends in health
care systems to promote brain health as a risk-reduction model and convene multi-disciplinary
stakeholders using community-based participatory research (CBPR)— involving mutual
relationships and partnerships with everyone involved at each phase of the research process
which is important in shaping individuals’ behavior and outcomes for the intervention. These
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approaches derive from social cognitive theory (SCT) and used to guide intervention research in
disease prevention among vulnerable populations (Brownson, Colditz, & Proctor, 2012). The
premise of this theory is that individuals will learn by observing and engaging throughout the
process together which confirms the role of modeling behavior and ultimately having champions
to carry the message and model brain health-protective behavior and physical activity awareness.
Efforts to address brain health among older African Americans began in 2006 at Rutgers
University-Newark, New Jersey. Initial efforts began with basic outreach and engagement at
local churches to educate older African American congregants about brain health and the risk of
AD and over the years has become a unique university led community partnership—The African
American Brain Health Initiative (AABHI). AABHI was designed to combine community
outreach and engagement, education, training, and brain health research to increase brain health
literacy among older African Americans (Gluck, Shaw, & Hill, 2018). Because of the success
and years of commitment, these grassroot efforts have led to ongoing funding from the National
Institute of Health’s (NIH) National Institute on Aging (NIA) and the Federal Office of Minority
Health/New Jersey Office of Minority and Multi-cultural Health (Gluck, et al., 2018).
Also joining the efforts to improve the lives of older adults, Bonnie Hart, owner of Food
and Nutrition Management Services, Inc. (FNMS)—developed BE WELL in 2003 to engage
older adults in the value of nutrition, low impact exercise and weight management to reduce the
risk of chronic health conditions such as diabetes, high blood pressure, heart disease, obesity, and
hyperlipidemia (Zina, 2014). Since the inception of BE WELL classes have been offered at least
twice a year and funded by the California Wellness Foundation and the City of Inglewood—with
additional funding from local agencies and organizations (Zina, 2014). To evaluate the
effectiveness of BE WELL, the City of Inglewood received a grant in September of 2013 to
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conduct a rigorous evaluation—comparing outcomes of seniors enrolled in program versus
seniors that did not enroll (Zina, 2014).
Under the direction of Dr. Karen Lincoln and Bryan Gaines, MSW at USC Suzanne
Dworak-Peck School of Social Work, AAAE was established to meet the growing needs of older
African Americans and their caregiving networks. This university-level collaborative focuses on
conducting CBPR, engaging in data collection, piloting interventions, and successfully providing
culturally competent outreach and health education. AAAE’s mission is to engage African
American elders in enhancing their quality of life through advocacy, education and increasing
access to community resources. The primary goals of the activities are to support policies that
will allow the most vulnerable older adults to age in place, increase the capacity of older adults
to advocate for themselves, and to increase the quality of life for African American seniors and
their families (Lincoln, 2018).
In 2014, AAAE administered a community survey to 550 AAs to better understand the
service needs of AA seniors in Los Angeles County. Data was collected on demographic
profiles, living arrangements and economic conditions, knowledge of healthcare policies,
physical and mental status, social support, food insufficiency, and computer and health literacy
from a convenience sample, self-administered survey designed by AAAE. Additionally, AAAE
administered a healthcare experience questionnaire to 200 AAs to measure their experience with
primary care and the healthcare setting using a self-report questionnaire designed by AAAE. In
2017, we launched our Healthy Brain Initiative by conducting a qualitative study to explore
African Americans’ knowledge about Alzheimer’s disease (AD) and attitudes toward clinical
research conducting four focus groups with 32 participants (Lincoln, Chow, Gaines, Hill, &
Fitzgerald, in press).
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Using data from the focus group we designed BrainWorks, a study to test a culturally-
tailored intervention to improve AD literacy among AAs. Methods included conducting a 3-arm
randomized trial with 193 participants. The AD literacy intervention consisted of: a) a control
group that attended a 60-minute talk show and received standard printed educational materials on
AD; b) an intervention group that received the same intervention as the control arm along with a
1-month, culturally-tailored, unidirectional, daily text-message program; and c) an intervention
group that received the same intervention as the control arm along with daily text messages that
the general population would receive. AD literacy was measured at baseline and at 1-month post-
intervention (Lincoln, et al., in press).
Results were promising, participants who received culturally-tailored text messages had
the highest increase in AD literacy levels, followed by those in the control arm. Participants who
received general text messages had a lower overall increase in AD literacy levels compared to
the control arm but had higher mean AD literacy levels than the control arm. Overall, AD
literacy among AAs can be improved through innovative educational formats enhanced with
technology (Lincoln, et al., in press). These are promising examples of current efforts to address
the impact of the risk for AD or a related dementia through the promotion of brain health.
Supporting evidence also derives from efforts at the Alzheimer’s Association—nation’s leading
organization in Alzheimer’s disease care, treatment, and research and other supporting
organizations.
Hence, efforts began with the release of the first Healthy Brain Initiative (HBI) Road
Map in 2007, developed by the National Alzheimer’s Association and the Center for Disease
Control and Prevention as a National Public Health Road Map to Maintaining Cognitive
Health—followed by a second edition in 2013 that focused on a Public Road Map for State and
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 20

National Partnerships (Alzheimer's Association and Centers for Healthy Brain Initiative, 2017).
The third edition was recently released in 2018 to promote State and Local Public Health
Partnerships to Address Dementia: The 2018-2023 Road Map (Alzheimer’s Association and
Center for Disease Control and Prevention, 2018) which provides basic guidelines for state and
local communities to address brain health on multiple levels and across various sectors including
case studies of successful brain health initiatives across the country. This edition also provides a
conceptual framework (see APPENDIX N for brain health framework) for addressing brain
health (Alzheimer’s Association and Center for Disease Control and Prevention, 2018) which
has been applied to the BE MINDFUL-BE WELL pilot study to facilitate the translation of
science to practice in real world settings, specifically in health care systems. Additionally, Us
Against Alzheimer’s-African Americans Against Alzheimer’s also focuses on promoting brain
health among African Americans through a variety of educational, theatrical, and political
arenas.
In 2017, the Alzheimer’s Association International Conference (AAIC), which convenes
the nation’s top scientist to discuss scientific advances in Alzheimer’s research to finding a cure
was dominated by research findings addressing modifiable health behaviors and the need for
prevention and intervention to address the risk associated with AD. These findings present
opportunities for further exploration, innovation, and potential funding for CBPR and other
targeted research efforts. For example, The Lancet International Commission on Dementia
Prevention, Intervention, and Care simultaneously published and presented findings at the AAIC
that more than one third of global dementia cases could be prevented by addressing lifestyle risk
factors that impact an individual’s risk for developing AD (Livingston, Sommerlad, Orgeta,
Castafreda, Huntley, Ames, …Mukadam, 2017) and the National Institute on Aging announced
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 21

research funding opportunities to investigate health disparities in AD (Alzheimer’s Association,
2017). These announcements are timely and support the efforts of this pilot study as well
opportunities for ongoing innovation to improve and promote brain health as an integrated risk-
reduction model for health care systems.
Methodology
Implementation Strategies
Using the Expert Recommendations for Implementing Change (ERIC) the following
strategy will be used for implementation: “Engage Consumers”— the ERIC classification to
prepare patient/consumers to be active participants is defined as “ to be active in their care, to ask
questions, and specifically to inquire about care guidelines, the evidence behind clinical
decisions, or about available evidence-supported treatments classified under the “Engage
Consumers” Cluster (number 50 in Figure 15.1) (Brownson, Colditz, & Proctor, p.250, 2017).
The proposed implementation strategy to “Engage Consumers” is critical to this effort
due to the barriers that exist within most large complex systems that could potentially have an
impact on sustainment. By engaging consumers as self-health advocates of a consumer-driven
and taxpayer health plan, we can mobilize LA Care members to assist with the integration of BE
MINDFUL-BE WELL as part of LA Care outreach, education, and engagement activities and
ultimately facilitate changes in policy to include the program as a paid healthcare benefit for all.
AAAEs existing staff, MSW student interns, Senior Advisory Committee (SAC)
comprised of 14 AA senior volunteers, core volunteers and student and community volunteers
are a well-established research team implementing CBPR for the past six years and will
implement the BE MINDFUL-BE WELL pilot project. CBPR will guide the following strategies
for implementation and the stages of the Exploration, Preparation, Implementation, &
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 22

Sustainment (EPIS) framework will facilitate the steps and timeline which began pre-
implementation in January of 2018 with donated time from all partners:
Exploration- pre-implementation
During pre-implementation stage AAAE research team organized internal strategic
planning meetings that outlined a detailed implementation plan for the pilot project. The detailed
implementation plan included coordinated meetings with collaborators and community partners
for engagement and discussion of implementation strategies. Then the team coordinated
meetings with LA Care data monitoring staff to discuss strategies for identifying AA members
and market focus groups to recruit participants.
Preparation- making decisions
We are currently in the pre-preparation stage of this pilot engaging the team, partners,
and potential participants. We hosted four focus groups at LA Care’s FRCs in Lynwood and
Inglewood with eight participants at each site and used findings to inform the design of culturally
relevant marketing tools, pre-screening, surveys, and talk show curriculum. During this stage the
team coordinated a meeting to design Brain Health Champion Bootcamp with BE WELL
designers and discuss implementation strategies for the bootcamp. The pilot is implementation
ready and all data collection staff will attend training that will cover human subjects training,
pre-screening & survey training, Qualtrics training, safety training and participate in field test to
ensure instruments, tools, and measures are functional and provide fidelity. We will video record
a live Brain Health Talk Show at a designated studio and recorded show will be used to deliver
the talk show component of pilot study. Lastly, prior to implementation we will host engagement
meetings and pre-screenings throughout various locations for LA Care members identified by
LA Care data monitoring team as 45 and older, AA, and presumed healthy.
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 23

Implementation- fidelity
The team will administer survey #1 with fidelity to 150 LA Care pre-screened eligible
participants and following survey #1 each participant will be randomized to three arms with
equal allocation (n=50). AAAE and LA Care will administer a direct mailing of Brain Health and
AD materials as “usual care” for Arm 1 participants, deliver two talks shows and distribute
tailored Brain Health and AD materials for Arms 2 & 3 participants, and then AAAE and Food
and Nutrition Management Services will deliver BE MINDFUL-BE WELL Brain Health
Champion Bootcamp for Arm 3 participants. The team will administer final survey #2 and
provide evaluations to all participants remaining in the pilot. Although attrition is expected, we
expect less than a five-percent dropout rate based on methods of engagement (i.e. follow-up
calls, emails, incentives etc.) throughout the entire study.
Sustainment- moving to scale
To determine satisfaction, elicit feedback, and discuss next steps to potentially move to
scale or expand our efforts, we will host two follow-up focus groups and viewing of videotaped
Talk Show, transcribe data, and report findings as lessons learned and future recommendations.
AAAEs PhD interns will analyze data for the pilot as part of their program of study. A full report
of findings will be authored by the AAAE research team and co-authored with partners. Deriving
from the full report, an infographic summary of the report will be designed for participants and
community dissemination. We will also host community presentations for LA Care participating
members, staff, and community partners and deploy our media campaign to disseminate findings
to stakeholders, elected officials, policy makers, local black newspapers & churches, aging
conferences, appear on local radio and live talk shows and submit full report for consideration in
various academic journals for publication.
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 24

Methods of Assessment
Specific Aims
Aim 1: Determine whether BE MINDFUL, a culturally tailored brain health education
program and workshop is more effective for increasing brain health knowledge and literacy vs.
usual care; Aim 2: Determine whether BE MINDFUL enhanced with a 6-week BE MINDFUL
BRAIN HEALTH CHAMPION BOOTCAMP (a modified version of the 4-month “BE WELL”
nutrition and exercise program designed for high risk older adults) targeting African Americans
is more effective for increasing brain health knowledge and literacy and improved health and
physical activity vs. usual care.
Target Population
According to Dr. Auleria Eakins, Community Outreach and Engagement Manager, LA
Care has been serving low-income diverse communities for over 20 years with over 2 million
members. Of the 2 million members 223,445 are African American and over 15,000 members
with both Medicare and MediCal. Los Angeles county is divided into eight service planning
areas (SPAs) and L. A. Care uses this designation for marketing, outreach, education, and service
planning with Family Resource Centers (FRCs) in each SPA (A. Eakins, personal
communication, March 2, 2018).
Recruitment methods will include, LA Care direct mailing to identified members, at LA
Care FRCs, LA Care Member Services referred Multipurpose Senior Services Program (MSSP)
and at LA Care scheduled community events and meetings. The LA Care FRCs located in
Inglewood and Lynwood, California will be the host sites for data collection, talks shows, and
weekly scheduled brain health boot camps. We will target LA Care AA Cal MediConnect
members that reside in: South Los Angeles, a geographic area that includes Crenshaw,
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 25

Inglewood, Exposition Park, Lynwood, Lennox, Ladera Heights, Hawthorne, West Adams,
Athens, Baldwin Hills, Hyde Park, Leimert Park, Gardena, Florence, and a section of Los
Angeles that spreads east toward the Harbor Freeway.
LA Care is well poised to explore the development of new knowledge and understanding
of adopting best practices to address risk factors associated with AD or related dementia through
brain health promotion at the health plan level that can be replicated, scaled, and sustained
through this exploration phase of piloting BE MINDFUL-BE WELL.
Study Design
From a pool of 226,224 AA LA Care members, total of 250 will be pre-screened using
pre-qualifying questions and a cognitive assessment measure using the Folstein Mini-Mental
Status Exam (MMSE): a practical method for grading the cognitive state of patients to determine
capacity to participate in study (Folstein, Folstein SE, & McHugh, 1975). All ineligible
participants due to cognitive impairment based on MMSE score will be referred to Alz
DirectConnect Referral-Alzheimer’s Greater Los Angeles and or the USC Family Caregiver
Support Center. A sample of 150 AAs, 45 years and older will be randomized to three arms with
equal allocation (n=50) (see APPENDIX O for study design).
The study design for BE MINDFUL-BE WELL is a 3-arm, randomized, controlled,
comparative effectiveness trial. At enrollment, participant characteristics will be collected,
including but not limited to sex, age, marital status, income, education, and health status. The
primary outcomes are brain health awareness, increased AD knowledge, and increased
knowledge of physical activity and health-protective behaviors for overall health and brain
health. Participants will be randomized after completion of baseline measurements, using a
random number generator, to one of three Arms:
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 26

• Baseline Measures: Administer Brain Health Questionnaire which will include:
Demographic Information (i.e. gender, race, ethnicity, age, marital status),
Alzheimer’s Disease Knowledge Scale (ADKS), and Short-Test of Functional Health
Literacy (S-TOFHLA).
• Arm 1: Talk show. Participants randomized to Arm 1 will receive the same
assessment and materials as the usual care control group but will also be randomized
to attend a two-hour talk show/information session held at LA Care Family Resource
Center (FRC). The BE MINDFUL-BE WELL curriculum will be delivered in an
interactive format (Talk Show/Resource & Information). The 2-hour BE MINDFUL-
BE WELL Talk Show/Workshop- will use existing and modified HBI curriculum
from Alzheimer’s Association and CDC Demonstration Project, including program
evaluation.
• Arm 2: Boot Camp. Participants randomized to Arm 2 will receive the same
assessment and materials as the usual care control group, will attend the talk show,
but will also receive a 6-week BE MINDFUL-BE WELL BRAIN HEALTH
CHAMPION BOOT CAMP- an interactive brain health, nutrition and exercise
program designed for high risk older adults which will include additional measures to
determine baseline measures before participation and follow-up measures after
participation in the program: Nutrition Risk Assessment, Depression Assessment
PHQ-9, The Lawton Instrumental Activities of Daily Living (IADLs), Activities of
Daily Living (ADLs) Questionnaire, and fitness tests.
• Arm 3: “Usual care”. Participants randomized into Arm 3 will receive standard
printed materials tailored African American brain health information from the
National Alzheimer’s Association and Center for Disease Control and Prevention
(CDC) Brain Health Campaign curriculum as “usual care” or standard practice sent to
participants via LA Care Health Plan direct mailing.
• Post Measures: Administer Post Brain Health Questionnaire: Alzheimer’s Disease
Knowledge Scale (ADKS), Short-Test of Functional Health Literacy (S-TOFHLA),
and overall participation satisfaction.
Measures
We will administer pre-screen measures for inclusion in study using the Folstein Mini-
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 27

Mental Status Exam (MMSE)—a practical method for grading the cognitive state of patients.
Participants enrolled in the study will be administered pre- brain health questionnaire which will
include: demographic information (i.e. gender, race, ethnicity, age, marital status), Alzheimer’s
Disease Knowledge Scale (ADKS) to assess level of AD knowledge, Short-Test of Functional
Health Literacy (S-TOFHLA) to assess current level of health literacy. Participants randomized
to arm two of the study will be administered boot camp measurements—measured at base line,
program completion at 6-weeks, and at 6-month following (optional) maintenance program. We
will collect weekly measures for weight, blood pressure, body fat, weight, and Body Mass Index
(BMI). Baseline measures will include assessing nutrition risk using the Nutrition Risk
Assessment, assessing for depression using the PHQ-9 Depression Assessment scale, assessment
of daily activities using Activities of Daily Living (ADLs) questionnaire, additional assessment
of instrumental activities (e.g. balancing check book, paying bills, etc.) using the Lawton
Instrumental Activities of Daily Living (IADLs) scale, and an overall fitness test to asses level of
fitness will be determined by various fitness tests that measure flexibility, strength, and stamina.
Finally, we will administer post measures, overall satisfaction surveys for participation,
focus groups, and in-depth interviews with participants, staff, and community partners. These
scales were selected because of ease of use and demonstrated validity, reliability, and
applicability to different groups (see Appendix P).
Project Budget
A detailed projected line-item budget to conduct the pilot for one year is included (see
APPENDIX Q) and additional projections will be determined upon completion of the pilot for
exploration of replication and associated cost for integration within existing health care systems.
AAAE is also collaborating with the School of Social Work (SSW) Office of Advancement to
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 28

increase its efforts to seek additional philanthropic resources needed to help sustain the project
after year one. Potential foundation support after year one includes: Archstone Foundation,
Allegan Company, Kaiser Permanente, Atlantic Philanthropies, Eisner Foundation, and the
MetLife Foundation to name a few. To identify new philanthropic prospects, the SSW has
significantly expanded its Advancement Office with a new Director of Corporate and Foundation
Relations, who is charged with identifying and securing six-figure philanthropic gifts in support
of the SSW and its many initiatives. AAAE is a priority area for the SSW’s philanthropic efforts,
and faculty and staff members work closely with the Advancement Office to identify funding
priorities in alignment with AAAE goals, activities, and projects such as BE MINDFUL-BE
WELL.
Ethical Concerns
The protection of human subjects is a common practice for AAAE, all staff are
Collaborative Institutional Training Initiative (CITI) trained & certified and prior to each study
we conduct an internal human subject training. All requirements of USC Institutional Review
Board (IRB) will be met prior to recruitment of study participants and study information sheets
and informed consent forms will be drafted for dissemination. The study information sheet
includes detailed information about study, addresses potential study concerns, and lists contact
information for principal investigator to resolve any additional concerns regarding the protection
of human subjects.
Implication to Practice
The proposed randomized comparative effectiveness trial will (1) provide support for
activities that will address questions related to the promotion and barriers to engaging
community-dwelling African American older adults in brain health-protective behaviors and
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 29

physical activity, (2) establish a multidisciplinary implementation team, and (3) produce
preliminary data that will support future funding for interventions to improve participation in
brain health-protective behaviors and physical activity for local health plans. Currently, there are
no studies that have used a talk show model to raise awareness about brain health-protective
behaviors and physical activity awareness to reduce risk of AD among older African Americans.
Health plans have a critical role and responsibility to provide health literacy for members and
must be reengineered to decrease health literacy demands to avoid health risk as members
traverse the health care system (Institute of Medicine (US) Roundtable on Health Literacy.
Measures of Health Literacy, 2009).
Specifically, this Randomized Control Trial (RCT) would be the first brain health risk
reduction program piloted through a local health care plan to address primary limitations in
health equity for older African Americans at risk for AD or related dementias. By offering brain
health risk reduction education, and engagement, a health care system can exclusively focus the
populations of greatest risk to consider a wider range of issues for replicating the model with
various populations. Implementing this model at the nation’s largest publicly operated health
plan serving low-income diverse communities for over 20 years, could have huge implications
for the Grand Challenge of Social Work-Closing the Health Gap as existing health plans address
the gap in brain health literacy and reducing the risk of AD—impacting the rising cost the
nation’s health care system.
The proposed solution will also assist in developing comprehensive brain health & AD
literacy and a more efficient system needed to provide brain health risk-reduction education,
early detection of cognitive impairment, and timely treatment and care for LA Care members and
their caregiving networks. The pilot will potentially identify members that are “high risk” and
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 30

members “at risk” for cognitive decline for referrals to education, assessment, or care
consultation. The proposed project could potentially introduce a broad range of Brain Health &
AD services to LA Care members that will improve their health care experience, especially those
who are underserved, vulnerable, high risk, and high cost.
LA Care has the potential to successful implement the proposed solution; yet, potential
barriers are critical to facilitating successful implementation. The organizational structure of LA
Care may require working with more than one lead within LA Care for implementation and a
potential barrier with leadership turnover—may cause delays. As leadership changes, priorities
and goals could shift and possibly change the direction of LA Care that excludes brain health
literacy as a priority. Also, the degree to which documents and signatures are required from LA
Care, turnaround time is a potential barrier due to the complexity legal departments
responsibility to understand and approve all documents. Staff motivation and readiness to change
and implement such practices could also be a potential barrier at this stage where the work
begins. Lastly, the readiness to change among the targeted population is a barrier due to
participates history of poor lifestyle choices and follow-through. We have determined alternative
strategies to address potential challenges (see APPENDIX R).
If this RCT demonstrates superior improvements in brain health and AD knowledge and
engaging in health-protective behaviors in the intervention group compared to the control group
and is found to be sustainable and scalable, BE MINDFUL-BE WELL could serve as a primary
brain health risk reduction model for racial/ethnic communities across the nation.
Conclusion
AAAE has been successfully providing culturally competent outreach and health
education for African Americans throughout Los Angeles County over six years—leading the
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 31

efforts in AD CBPR at USC Suzanne Dworak-Peck School of Social Work (Lincoln, 2018). As
mentioned, AAAE recently conducted a qualitative study to explore African Americans’
knowledge about Alzheimer’s disease (AD) and attitudes toward clinical research conducting
four focus groups with 32 participants and most recently, we completed BrainWorks, a study to
test a culturally-tailored intervention to improve AD literacy among AAs, both studies funded by
Southern California Clinical and Translational Science Institute (CTSI) and USC Alzheimer’s
Disease Research Center (ADRC). The significance of our work is featured in Generations,
Journal of the American Society on Aging, Summer 2018, PARTNERS- USC Suzanne Dworak-
Peck School of Social Work, and USC Spotlight video. We also, two publications in press with
the American Journal of Geriatric Psychiatry, and Ethnicity and Health.
As a result of our success with the Wisdom Project and BrainWorks, we plan to submit
this proposal to the CTSI and ADRC in January of 2019 to support the pilot study and upon
completion explore feasibility of expanding the study to further investigate the impact of
modifying life-style behaviors to lower risk of AD by explicitly identifying biomarkers using the
least noninvasive measures. For example, we propose to benchmark the amyloid tau status from
blood measures, and screen with two new biomarker approaches from non-invasive samples of
urine and retinal photography. By adding these biomarkers to our existing study, we could
potentially have ground breaking data on brain functioning and evidence of any brain changes
post BE MINDFUL-BE WELL interactive brain health program.
In closing, two legislative hearings are in discussion with Congresswoman Maxine
Waters to determine funding mechanisms to promote risk-reduction brain health models,
investigate how NIH funds AD research versus CBPR, and request oversight and transparency
for designated organizations and agencies receiving federal funding to provide AD programs and
BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 32

services (see Appendix S for information on policy recommendations and priorities). This effort
is a direct result from sharing this proposal with the congresswoman and offering solutions to
provide optimal care for older African Americans through the promotion of brain health—
ultimately closing a gap in health care and disrupting one of the most inhuman social
injustices—access to quality care for all.

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Appendix

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Appendix A
There’s A Killer Among Us

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BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 36

Appendix B
Advocates for African American Elders (AAAE)
Our Mission
To engage African American elders in enhancing their quality of life through advocacy, education and
increasing access to community resources.
About Advocates for African American Elders

Advocates for African American Elders (AAAE) is an outreach and engagement partnership of
academic, governmental, nonprofit, and community groups whose aim is to help older African
Americans in Los Angeles advocate for their health and mental health needs.

The formation of AAAE is timely because
by 2050, the number of African
Americans age 65 and older will more
than triple nationwide. Consequently, the
percentage of chronic health conditions
(e.g., hypertension, diabetes, obesity),
mental health disorders (e.g.,
depression), Alzheimer’s disease and
dementia will also increase. Despite
growing numbers of Black seniors, many
existing programs and services are
unable to effectively serve them due, in
part, to the difficulty of identifying,
outreaching and engaging those who
need services the most. The increased
need for services and significant
decrease in funding for older adult
services clearly points to the need for greater advocacy, outreach, engagement and culturally
competent services.

As well as catalyzing general advocacy efforts to improve the delivery of health services for African
American communities in Los Angeles County, the partnership seeks to strengthen collaboration
between agencies and community organizations, develop training programs and mental health
interventions specifically tailored for African American older adults, and increase health literacy.

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Appendix C
L.A. Care Health Plan Letter of Support

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Appendix D
Risk Reduction Model. The Lancet 2017 390, 2673-2734DOI: (10.1016/S0140-6736(17)31363-6

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 39

Appendix E
Project Logic Model

PILOT PROJECT LOGIC MODEL

NAME OF PILOT PROJECT:
“BE MINDFUL-BE WELL”: A 1-year pilot project designed to increase brain health & Alzheimer’s disease (AD) literacy, and awareness of
physical activity & health-protective behaviors within the nation’s largest publicly operated health care system, LA Care Health Plan (LA Care).

GRAND CHALLENGE AREA:
The Grand Challenge of Closing the Health Gap aims to eliminate health disparities and inequities.

KEY BENEFITS:
The proposed pilot project “BE MINDFUL-BE WELL” aims to address Health Equity by focusing on risk reduction for Alzheimer’s disease and
related dementias through the promotion of brain health and awareness of modifiable behaviors:
✓ Increase brain health and Alzheimer’s disease literacy
✓ Raise awareness of physical activity and health-protective behaviors
✓ Lower risk for Alzheimer’s and related dementias

INPUTS
OUTPUTS OUTCOMES
Activities Participants Short-term Medium-term Long-term
USC, Dean, Faculty,
and Staff.
USC IRB
LA Care Health Plan
Collaborative Partners
Community Partners
Volunteers
Time
Funding
Data Collection
Research Findings
Recruitment
Materials
Equipment
Technology

Total number of
bootcamp sessions
completed
Percentage of
weight loss
Percentage of lower
blood pressure
Total number of
steps
Percentage of
cognitive
assessments

Total number of
members pre-
screened
Total number
enrolled
Total number of
dropouts
Total number
remaining in study
Total number of
bootcamp champions
recruited

Increase Brain
Health & AD Health
Literacy.
Increase awareness
of AD risk factors.
Increase awareness
of health protective
behaviors and
physical activity.
Increase knowledge
about screenings,
assessments, early
detection, and
access to resources.
Increase self-health
advocacy.
Decrease intent to
engage in unhealthy
behaviors.
Increase intent to
engage in physical
activity.
Increase intent to
request cognitive
screenings.

Create Brain Health
Champions
Greater access to risk-
reduction programs and
services.
Greater access to early
stage interventions.
Integration of “BE
MINDFUL-BE WELL” as
a health care benefit.
Integrate “BE MINDFUL-
Be Well” curriculum as
part of LA Care’s
existing education and
outreach efforts.

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Appendix F
Pilot Artifact

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Appendix G
AAAE Talk Show Model

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BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 45

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 46

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 47

Appendix H
Talk Curriculum

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BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 49

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 50

Appendix I
BE MINDFUL-BE WELL 6-Week Prototype

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Appendix J
Bootcamp Curriculum

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BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 53

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 54

Appendix K
Brain Health Champion Celebration

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Appendix L
Optional Maintenance Program

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Appendix M
A Social Determinants Framework

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Appendix N
Healthy Brain Conceptual Framework (2018). Alzheimer's Association and Centers for Disease
Control and Prevention.

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Appendix O
Pilot Study Design

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Mini Cog- 6-item screener which is a brief and reliable test with comparable diagnostic properties to the full
Mini Mental State Exam. Cronbach's alpha coefficient 0.874.
Alzheimer’s Disease Knowledge Scale (ADKS)- a 30-questions true-or-false scale. Adequate reliability
(test–retest correlation = .81; internal consistency reliability = .71) and validity (content, predictive,
concurrent, and convergent).
Short-Test of Functional Health Literacy (S-TOFHLA)- a short 7-minute test to measure health functioning.
Cronbach's alpha 0.68
Nutrition Risk Assessment- Level 1-DETERMINE Nutritional Health checklist-10-questions that can be
easily graded to determine a person’s nutritional health. Level 2-Activities of Daily Living (ADLs)
Questionnaire-Widely used tool.
Senior Fitness Test (SFT) Cal State Fullerton, Rikli & Jones- weight, number of steps walked, blood
pressure, and attendance-Reliability and validity indicators for the standards ranged between .79 and .97.
Patient Health Questionnaire (PHQ-9) 9 items, depression scale- for the diagnosis of any 1 or more PHQ
disorder, κ = 0.65; overall accuracy, 85%; sensitivity, 75%; specificity, 90%.

The Lawton Instrumental Activities of Daily Living Scale-Inter-rater reliability was established at 0.85. The
validity of the Lawton IADL was tested by determining the correlation of the Lawton IADL with four scales
that measured domains of functional status, the Physical Classification (6-point rating of physical health),
Mental Status Questionnaire (10-point test of orientation and memory), Behavior and Adjustment rating
scales (4-6-point measure of intellectual, person, behavioral and social adjustment), and the PSMS (6-item
ADLs).

Appendix P

Validity and Reliability of Measurement Tools
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Appendix Q
Pilot Project Budget

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 61

Appendix R
Potential Challenges and Alternative Strategies

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 62

Appendix S
Hill Visit- Policies and Priorities

BE MINDFUL-BE WELL: A RANDOMIZED COMPARATIVE EFFECTIVENESS TRIAL 63

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Abstract (if available)

Abstract Capstone Project: Grand Challenge of Social Work—Closing the Health Gap ❧ “BE MINDFUL-BE WELL” is a pilot project designed to implement brain health & Alzheimer’s disease literacy, and awareness of physical activity & health-protective behaviors within the nation’s largest publicly operated health care system, LA Care Health Plan. The specific aims are: 1) To determine whether, “BE MINDFUL-BE WELL”: a tailored brain health education program and workshop (AAAE Talk Show Model) is more effective for increasing brain health knowledge and literacy vs. usual care, and 2) To determine whether “BE MINDFUL-BE WELL” enhanced with a 6-week” BE MINDFUL-BE WELL BRAIN HEALTH CHAMPION BOOTCAMP” (BE WELL Model) targeting African Americans (AAs) is more effective for increasing brain health literacy and improved health and physical activity vs. usual care.

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Creator Gaines, Bryan F. (author)

Core Title Be mindful—be well: a randomized comparative effectiveness trial—addressing brain health among older African Africans

School Suzanne Dworak-Peck School of Social Work

Degree Doctor of Social Work

Degree Program Social Work

Publication Date 03/12/2021

Defense Date 11/30/2018

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag African Americans, Blacks, diabetes, hypertension (high blood pressure),Alzheimer's disease,Alzheimer's disease literacy,brain health,brain health education,dementia,Exercise,health care,health care systems,Health education,health literacy,health-protective behaviors,healthy brain,high cholesterol,Nutrition,OAI-PMH Harvest,physical activity,risk-reduction models

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Language English

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Advisor Navarro, Ernelyn J. (committee chair), Lincoln, Karen D. (committee member)

Creator Email bfg@usc.edu,bryangaines16@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c89-132933

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