Source: UNIV OF MARYLAND submitted to NRP
EFFECTS OF AN INTEGRATED SYSTEM APPROACH ON HYPERTENSION MANAGEMENT IN COMMUNITY DWELLING OLDER ADULTS
Sponsoring Institution
National Institute of Food and Agriculture
Project Status
COMPLETE
Funding Source
AFRI COMPETITIVE GRANT
Reporting Frequency
Annual
Accession No.
1024389
Grant No.
2021-68015-33435
Cumulative Award Amt.
$547,752.00
Proposal No.
2020-03355
Multistate No.
(N/A)
Project Start Date
Jan 1, 2021
Project End Date
Dec 31, 2024
Grant Year
2021
Program Code
[A1344]- Diet, Nutrition and the Prevention of Chronic Disease
Recipient Organization
UNIV OF MARYLAND
(N/A)
COLLEGE PARK,MD 20742
Performing Department
NFSC
Non Technical Summary
The long-term goal of this integrated project is to build a sustainable, community-based hypertension management program by combining research methodologies, an extension system and educational activities.In order to achieve this goal, we will:(1) Develop a theory-driven, community-based hypertension self-management program. Using a matched-pair, cluster randomization, 16 community sites throughout 8 Maryland counties will be selected and 240 hypertensive older adults (≥60) will be recruited.The intervention will consist of i) an 8-week DASH-plus education (Dietary Approaches to Stop Hypertension diet with exercise and hypertension self-care skills), ii) 'Imperfect Foods' produce delivery to increase produce accessibility and iii) self-measured blood pressure monitoring. An hypertension recipe booklet tailored to the nutritional needs of older adults will also be developed by dietetic students through a formal classroom setting. Further, a culture of heath will be promoted through a peer support model.(2) Test the effectiveness of the program in improving hypertension-related outcomes (blood pressure, self-care skills, diet quality, perceived produce accessibility) and whether the program effectiveness differs according to moderating variables such as race, gender, and geographical location.(3) Disseminate the program through the extension system. In the final year, the approach will be integrated into the University of Maryland Extension program to deliver it to various community sites.By leveraging existing resources from the aging network, extension, produce delivery approach and education system, this study will demonstrate creative and feasible means to tackle uncontrolled blood pressure in older adults. This concerted action among stakeholders will expedite interdisciplinary knowledge.
Animal Health Component
80%
Research Effort Categories
Basic
(N/A)
Applied
80%
Developmental
20%
Classification

Knowledge Area (KA)Subject of Investigation (SOI)Field of Science (FOS)Percent
7036099101080%
7046099101020%
Knowledge Area
703 - Nutrition Education and Behavior; 704 - Nutrition and Hunger in the Population;

Subject Of Investigation
6099 - People and communities, general/other;

Field Of Science
1010 - Nutrition and metabolism;
Goals / Objectives
Older adults are the fastest growing segment of the population; by 2040, about 22% of the US population will be aged 65 or older. With the aging of the population, the health status of older adults has drawn a great deal of attention from health professionals, since their health status can result in a significant impact on the U.S. health care systems and social services including tremendous health care costs. Among major chronic diseases, elevated blood pressure (BP) represents a primary risk factor not only for cardiovascular complications but also for cognitive decline and loss of autonomy later in life. Two-thirds of older adults have hypertension (HTN) and this group has the lowest BP control rate. If not managed properly, deteriorating health conditions of older adults will consume enormous resources over the next decade.To tackle this prevalent and persistent disease, an integrated approach at the system level through collaborative partnerships will be effective and essential. The overall objective of this integrated project is to develop, implement, evaluate and sustain an innovative HTN management program for older adults by combining research methodologies, the extension system and educational activities. The research methodologies will apply evidence-based findings to translational research at the community level, and the extension system and educational activities will ensure long-term sustainability and cultivate a future workforce for nutrition. The project will also establish a systematic translation process through the extension system and will demonstrate how dynamic interplay among research, extension and education can be used to address knowledge gaps in translational research.Proper HTN management requires both pharmacological and non-pharmacological strategies. Lifestyle modification should be considered as the first line of non-pharmacological approaches. According to the Eighth Joint National Committee on Prevention, Detection, Evaluation and Treatment of High Blood Pressure (JNC 8), a heart-healthy diet, sodium reduction, increased physical activity, abstinence from or moderation in alcohol consumption, and use of home BP monitoring are key recommended strategies. However, unique physical and mental health needs make older adults notably susceptible to HTN and its management.The Dietary Approaches to Stop Hypertension (DASH) diet has been suggested as an integral part of HTN management Although ample clinical evidence supports the positive effect of DASH on cardiovascular disease (CVD) risks, community-based trials are limited. The translation of DASH into various community-based settings is crucial to generate results with greater practical application, test external validity, and examine dissemination strategies for best practices. Further, the sustainability of a community-based DASH program should be fully explored.In general, translational research is considered to be the process of turning observations and knowledge generated from laboratory, clinic, and community settings to interventions and tools that improve the health of individuals and populations. Although there is no clear consensus, translational research phases include T1 ("From Bench to Bedside"), T2 ("From Bedside to Clinical Practice", establishment of effectiveness in humans and clinical guidelines), T3 ("From Clinical Practice to Widespread Practice", community-based participatory research [CBPR]), and T4 ("Impact on the Community", wider dissemination/implementation of interventions). In particular, bringing the benefits of scientific findings from the medical field into communities is the focus of T3 and T4 and these phases are critical to achieve intended health outcomes and social impact of research at the population level. Considering insufficient evidence of DASH-based HTN management among older adults at T3 and T4 phases, testing the effectiveness of the proposed intervention at these translational stages will be very beneficial to understand how such strategies work and can be sustained in real world settings for free living individuals.Along with a healthy diet, regular exercise and self-measured blood pressure monitoring (SMBP) are also well-proven lifestyle modification strategies to lower BP and improve heart health. Through SMBP, older adults can be actively engaged in self-managing their HTN, resulting in positive health outcomes. Additional HTN self-care behaviors include medication adherence, smoking cessation, moderate alcohol consumption, and weight management and there is strong evidence that self-care behaviors are effective in achieving BP control.Our long-term goal is to build a sustainable, community-based HTN management program to reduce morbidity and mortality rates associated with high BP among older adults by integrating people, processes and systems. In order to achieve this long-term goal, the proposed study aims to develop, implement, and evaluate a multifaceted HTN management program at community sites (T3) and disseminate the program through the extension system for long-term sustainability (T4). The proposed approaches are developed by integrating content from evidence-based findings and are also informed by extensive community assessments and key stakeholder interviews. We will conduct the T3 translational research in Years 1 and 2 (to produce generalizable knowledge about the intervention in real world settings) and the T4 phase in Years 2 and 3 (to widely disseminate intervention and practice into communities). Both of the phases will be delivered through the extension system and integrated into a formal dietetic class and/or extension internship course, respectively, to provide students with educational opportunities, and equipped them to understand geriatric population, and role of extension.For the T3 phase, we propose a matched-pair, cluster randomized trial to assess the effectiveness of a community-based HTN program. 16 senior centers or community sites in 8 Maryland (MD) counties will be randomly selected and a total of 240 hypertensive older adults (≥60) attending senior centers, congregate meal sites or community activity centers will be recruited. The intervention will consist of 1) an 8-week DASH-plus education (DASH eating plan with exercise and other HTN self-care behaviors) for community-dwelling older adults, 2) a partnership with 'Imperfect Foods' (a company that sells "ugly" but perfectly edible produce at a reduced price) produce delivery approach to increase fruit and vegetable (FV) accessibility at affordable price and 3) SMBP for 24 weeks. Reducing barriers to help translate education into daily activities such as cooking are particularly important as well. Thus, an HTN recipe booklet tailored for the nutritional and physiological needs of hypertensive older adults will be provided to participants in the intervention. The booklet will be tailored and expanded upon by dietetic students through a formal classroom and lab setting. Further, students enrolled in a University of Maryland Extension (UME) internship course will have practical learning opportunities and advanced understanding of extension and nutritional science by supporting the program activities. Lastly, using a peer support model, a culture of health will be promoted and sustained. A peer supporter recruited at each intervention site will play a vital role in supporting their peers and sustaining the program at community sites.The study outcomes (BP, self-care behaviors including SMBP, diet quality, HTN knowledge, perceived FV accessibility) will be measured. After the T3 phase, T4 will be launched for program dissemination through the UME. A toolkit will be compiled, and the program will be disseminated throughout entire community sites, senior centers and congregate meal sites. State-wide evaluation measures will also be collected.
Project Methods
For the proposed intervention, we have assembled a team of experts including extension educators with extensive experience working with community, a national expert on family consumer science and evaluation, an assembly of national, state and local experts in community nutrition and/or CBPR research and state and local representatives in aging network. The intervention group (n = 120) will receive an 8-week DASH-Plus education delivered through the extension while concurrently using 'Imperfect Foods' produce delivery service and SMBP for 24 weeks. In addition to the intervention components, treatment strength (e.g., class attendance) and the level of adherence (e.g., SMBP frequency) are also conceptualized as an intervention factor and will be used for dose-response analysis.Process evaluation Since this is one of the few community-based DASH translational studies that employ a CBPR framework in older adults, process evaluation that includes assessments of dose (class attendance), fidelity (coverage of all DASH-Plus topics by educators, produce pick-up & maintenance) and operationally (interviews with Imperfect Foods) will offer much to the next phase.Key measuresBlood pressure measured using the Omron HEM 710-CP will be treated as a continuous variable as well as a dichotomous variable (controlled/not controlled). Based on the JNC 8 recommendation, the suggested goal of BP for older adults will be set at less than 150/90 mmHg.Self-care behaviors suggested by the JNC 8 recommendations will be assessed using the Hypertension Self-Care Activity Level Effects (H-Scale). The scale consists of six subscales (medication adherence, smoking, alcohol consumption, physical activity, diet, and weight management). Reliability analyses resulted in Cronbach's alpha coefficients = [0.67, 0.88] for the six subscales, demonstrating acceptable reliability for an intervention evaluation.Dietary assessment: Traditional dietary assessment methods are often too burdensome and time-consuming particularly for older adults. The Rapid Eating Assessment for Participants [shortened] is a simple measure that is validated and quickly assesses diet quality. The alpha coefficient was 0.78 in our 2015 needs assessment.Physical function will be assessed using self-reported ability to perform Instrumental Activities of Daily Living (IADL). The scale assesses a person's ability to perform tasks such as using a telephone, doing laundry, and handling finances.HTN knowledge: The Hypertension Evaluation of Lifestyle and Management (HELM) scale consists of 14 items and has been well validated; we used it in our preliminary work and obtained an alpha coefficient of 0.72.Depressive symptoms will be assessed using a 5-item of the Geriatric Depression Scale (GDS-5, score range 0-5 points). A summed score of 2 or more is considered as having depression.SMBP behavior: To assess the frequency and pattern of SMBP practice, each participant's BP data will be retrieved from individual, memory-equipped BP devices or 'My Blood Pressure Log' on a monthly basis by the research team.Perceived FV accessibility will be measured since perceived access to FV is associated with FV intake. Existing tools will be modified. The participants will be asked if they have difficulties with transport for food shopping, access to stores to buy FV, access to their own private vehicle, and access to any help if they need some assistance to go shopping.Satisfactory survey will be used to understand how well Imperfect Foods' produce delivery service is accepted and examine possible barriers and facilitators to continue and expand the service.Exit interviews with senior center directors, peer supporters, and older adults who dropped out will be conducted to examine program satisfaction, barriers, and facilitators related to program operation and sustainability.Students' course evaluation & feedback will be used as the study outcomes related to NFSC 350 and the UME internship course. For example, students will reflect and evaluate this hands-on educational project and discuss how they could increase nutrition care to older adults in the future.At the dissemination phase, the program will be evaluated using a brief pre, post-survey after program implementation. Older adults who attend at least six out of eight sessions will be included to assess the program outcomes. Key constructs of a brief pre, post survey include demographics, HTN knowledge, self-efficacy and intent to change behavior to generate the impact statement of the program at the extension system level. We will also use process evaluation measures to assess reach and fidelity to monitor and enhance the delivery of the program, as well as semi-structured interviews with participating site directors, staff or older adults to understand how well the program is adopted to those community sites.Analysis planGeneral analysis: The first step will be to graphically display major outcomes and explanatory variables to identify outlying observations and the need for transformation to simplify analyses and summarize the relationships among variables. Standard psychometric methods will be used to verify the psychometric properties of scales for the instruments. Also, univariate distributions will be inspected to assess normality. Aim-specific analysis: Compared with the control group, the intervention group will have (1) a greater reduction in BP, (2) improved self-care behaviors, diet quality, HTN knowledge, 3) better FV accessibility, and 4) frequent SMBP (Aim 2). GEE will be used to examine the study outcomes to analyze individual-level data while accounting for the cluster averaged effects and the correlation. The GEE model is adopted due to the possible correlation structure among the repeated measurements at baseline, 8 weeks, and 24 weeks. GEE uses the generalized linear model to estimate more efficient and unbiased regression parameters relative to ordinary least squares regression. This is in part because GEE permits specification of a working correlation matrix that accounts for the form of within-subject correlation of responses on dependent variables of many different distributions. We will adopt auto regression with lag 1 as the correlational structure as that is most likely to be correct considering the repeated measures over time. With individual BP, HTN knowledge, self-care behaviors, and diet quality outcome scores as the dependent variable, we will first assess the interaction effect between conditions and time. If this term is significant, the simple effect (comparing conditions at each time point) will be assessed. If the interaction term is not significant, the main effect (comparing condition across all time points) will be assessed. "Treatment as delivered" analysis will be used for the intervention group to assess the dose-response association with treatment strength (e.g., attendance in DASH-Plus education), level of adherence (e.g.,SMBP frequency), and outcome variables (e.g., changes in BP, HTN knowledge, diet quality). Also, using GEE, the effectiveness of the program will be evaluated with consideration of moderating variables. To measure system-level sustainability, exit interviews with senior center directors, peer supporters and older adults who dropped out will be collected. (Aim 2). Since missing data are likely to occur in studies of older populations, complete case analysis will also be conducted. Process data will be used to examine reach and fidelity of the interventions. A brief pre, post survey will be administered before and after the dissemination of the intervention at target sites. Simple paired t-test and regression model using change scores will be used to examine change over time (Aim 3)

Progress 01/01/21 to 12/31/24

Outputs
Target Audience:Community-dwelling, hypertensive older adults were the primary target audience of the present project. With the aging of the population, the health status of older adults has drawn a great deal of attention from health professionals, since their health status can have a significant impact on the U.S. health-care systems and social services. Elevated blood pressure represents a primary risk factor not only for cardiovascular complications but also for cognitive decline and loss of autonomy later in life. Two-thirds of older adults have hypertension and this group has the lowest blood pressure control rate. For the present study, the primary target individuals are older adults who are (1) ≥60 years of age, (2) attend the Older Americans Act Nutrition Program or other community site for seniors regularly (at least three times per week), and (3) has a systolic blood pressure of 130-170 mm Hg and/or a diastolic blood pressure of 80-100 mm Hg or hypertension medication. Older adults were excluded if they (1) have an acute and/or terminal condition such as terminal cancer, renal disease, and/or high alcohol consumption (>14 alcoholic drinks per week), (2) have a psychiatric diagnosis precluding participation, such as cognitive impairment as measured by the 6-item Mini-Mental State Exam, and (3) are underweight (BMI 18.5) or class 3 obese (BMI 45.0kg/m2). Throughout the project, approximately 440 older adults participated in the DASH-Plus education series. Below are additional details about the target audience: Year 1: Due to COVID-19, the program was conducted virtually instead of in person. Although a virtual education component was not part of the original plan, our team was eager to provide educational benefits to the community, especially during the pandemic. The team offered eight educational sessions online, with 352 older adults registering and 74 attending at least one session. Years 2 & 3: A total of 212 older adults enrolled in the Phase 3 translational study (T3). In 2023, the team also provided delayed interventions for control group participants from the previous fiscal year, reaching approximately 74 individuals. To expand the program's impact, the team also offered the intervention to other interested seniors who had not previously participated. Year 4: To disseminate the program and explore its long-term sustainability, Phase 4 translational study (T4) was offered to the communities of interest and the expanded program successfully engaged 80 older adults across senior centers and YMCA locations. Changes/Problems:Originally, the research team planned to employ a cluster randomization method to recruit study sites, and participants and test the effectiveness of proposed intervention approaches. In 2022, most states across the country including Maryland had been dropping COVID-related regulations since the lockdown in 2019. However, many potential community sites for the project were still not fully functioning and older adults attending community sites and senior centers have not yet completely resumed their daily activities in community sites. Further, it could not be guaranteed that COVID regulation would be completely lifted for human subject studies throughout this reporting period and there might still be a chance to go back into full or partial lockdown again. Considering the fluid situation in 2022, the team reached a consensus that a quasi-experimental approach might be a better option to recruit sites and study participants and retain them at this point. This request had been submitted and approved by the funder. What opportunities for training and professional development has the project provided?The DASH-Plus project has emerged as a robust platform for multidisciplinary research training and professional development, providing learning experiences for students across various academic levels. Through strategic partnerships with the University of Maryland's Department of Nutrition and Food Science, the project has created meaningful educational opportunities that extend far beyond traditional classroom learning. The dietetics program at the University of Maryland College Park integrated the DASH-Plus project into its Food Service Operation course for junior and senior students. This approach allowed students to move beyond theoretical knowledge, engaging them directly in practical research activities. During the 2020 and 2021 semesters, students actively participated in developing and testing hypertension-friendly recipes specifically designed for older adults. The semester's culmination featured student presentations where they shared their experiences, insights, and culinary innovations, bridging academic learning with real-world health intervention strategies. From 2021 to 2023, the project expanded its educational impact through the University of Maryland Extension internship course. This program provided students with comprehensive, hands-on learning experiences in community health research and extension work. Interns underwent online training modules before being integrated into the project's research teams. The internship experience was multifaceted, offering students practical opportunities to contribute to critical research activities. Interns actively supported process and impact evaluations, collaborated on developing project materials and gained insights into the intricate workings of extension programs. By working closely with extension professionals, students developed a nuanced understanding of program implementation, evaluation methodologies, and community-based research approaches. Recognizing the importance of continuous learning, Family and Consumer Science educators received dedicated support through annual training workshops from 2021 to 2023. These workshops provided opportunities for professional growth, knowledge sharing, and skill enhancement. Additionally, educators were encouraged and supported in attending professional conferences, further expanding their professional networks and staying current with emerging research and best practices in community health interventions. How have the results been disseminated to communities of interest?The long-term vision of this integrated project is to establish a sustainable, community-based hypertension management program that extends beyond the initial research phase. The DASH-Plus initiative is strategically designed to develop a replicable intervention that can be effectively disseminated and maintained at the community level. The project's key objective is to transform research findings into a practical, community-driven health intervention that can be replicated and sustained over time. Detailed information about the dissemination and sustainability strategies can be found in the 'Accomplishments' section, specifically under Aim 3, which provides a comprehensive overview of the program's long-term implementation plan. What do you plan to do during the next reporting period to accomplish the goals? Nothing Reported

Impacts
What was accomplished under these goals? The long-term goal of this integrated project is to build a sustainable, community-based hypertension management program by combining research methodologies, an extension system and educational activities. Aim 1: Develop a theory-driven, community-based hypertension self-management program composed of DASH-Plus education, fresh produce delivery and self-measured blood pressure monitoring practice by partnering with key stakeholders. Our team successfully developed a theory-driven hypertension self-management program for community-dwelling older adults, strategically guided by the Social Ecological Model and community-based participatory research principles. The comprehensive approach integrated evidence-based interventions with community-specific needs and resources. 1. DASH-Plus Educational Curriculum We designed an innovative 8-week DASH-Plus education curriculum, complemented by comprehensive facilitator manuals. The curriculum has been rigorously tested and is prepared for widespread dissemination, offering a robust framework for hypertension management among older populations. 2. Produce delivery to improve produce Accessibility To address fresh produce accessibility barriers, we established strategic partnerships with local and regional farmers and produce delivery companies. These collaborations significantly enhanced produce accessibility for participating seniors. Even after initial funding concluded, we maintained a scaled-back produce delivery system, demonstrating the program's sustainability and community commitment. 3. Blood Pressure Monitoring During the translational research phase 3, we equipped participants with individual blood pressure monitors to promote regular self-monitoring. Following the project's completion, we supported local senior centers by providing 1-2 blood pressure monitors, enabling seniors to track their health conveniently during center visits. Aim 2: Test the effectiveness of the program in improving hypertension-related outcomes (T3 translational research) Virtual, synchronous DASH-Plus Hypertension Education Program for Maryland Seniors In 2021, our team launched a virtual DASH-Plus hypertension program to support older adults in Maryland amid COVID-19 restrictions although this virtual approach was not included in the proposed application. Designed for adults 55+ with hypertension, the program was led by nine University of Maryland Extension FCS educators and delivered online over eight weeks (July-October 2021). Sessions covered sodium reduction, whole grains, low-fat dairy, and creative fruit and vegetable recipes, tailored to Maryland's diverse regions. Educators received state-wide training in May 2021 before co-teaching 24 virtual sessions. Of 352 registrants, 74 actively participated, with 28 attendees per session on average. Key Outcomes (Pre- vs. Post-Survey Results) Hypertension Knowledge: Significant improvement (p=0.021) Sodium Reduction: Perceived benefits increased (p=0.004) Whole Grains: Improved perceived benefits (p=0.001), self-efficacy (p=0.012), and readiness to change (p=0.011) Fruit & Vegetables: Increased self-efficacy (p=0.024) and readiness to eat more (p=0.046) Shopping: Improved knowledge of food date labels (p=0.05) Meats & Proteins: Greater perceived benefits (p=0.034) and self-efficacy (p=0.035) Fats & Sweets: Improved self-efficacy for healthier choices (p=0.034) T3 translational research In early 2022, our team launched the project as originally planned. We engaged 14 senior centers across seven counties, with two sites per county, except Baltimore, which contributed four to meet research needs Participant Recruitment and Study Design Participants were required to be 60+, attend senior centers or nutrition sites at least three times weekly, and meet specific blood pressure criteria (systolic 130-170 mm Hg, diastolic 80-100 mm Hg, or on hypertension medication). Due to COVID-19, the study shifted from a matched-pair, cluster randomization design to a quasi-experimental approach, approved by the funding agency. 2. Program implementation and outcomes From May 2022, seven FCS educators implemented a comprehensive intervention strategy. The intervention group participated in an intensive 8-week DASH+ program, while the control group engaged in a 4-week Wellness+ program. Participants in the intervention group received the 8-week educational series, weekly produce delivery spanning 24 weeks, and an individual blood pressure monitor. The control group participated in bi-weekly wellness education and received small promotional items. A total of 211 hypertensive older adults completed the study, participating in comprehensive surveys at baseline, 8 weeks, and 24 weeks. At the 8-week mark, the intervention group demonstrated statistically significant improvements across multiple health indicators. Fruit consumption saw a dramatic increase, with participants meeting recommended intake levels rising from approximately 56% at baseline to 81%. Statistically significant improvements were observed in systolic and diastolic blood pressures (p=.003 and .002, respectively), fruit and vegetable consumption (p=.001 for both), hypertension knowledge (p=.001), medication adherence (p=.013), and physical activity (p=.001). The contrast between intervention and control groups was meaningful. While the intervention group showed substantial health improvements, the control group experienced no significant changes in blood pressure, medication adherence, knowledge, or physical activity. Particularly concerning was the significant decrease in low-salt diet adherence among the control group at the 8-week point. The 24-week data analysis is currently in progress. Delayed intervention after T3 translational research Between April and November 2023, the team conducted a delayed intervention to benefit the prior control group and strengthen community partnerships. Sessions were also opened to additional community members to expand impact. The eight-week program included educational modules, weekly produce bags (3-8 deliveries per site), and blood pressure monitors for senior centers to support self-monitoring. With 74 participants across six counties, the program measured hypertension knowledge, self-efficacy, perceived benefits, and behavioral readiness. After completing the program, participants reported stronger perceived benefits associated with making hypertension-management changes, and increased readiness to implement healthy change. Self-efficacy statistically significantly improved across all sessions.Additionally, participants showed a statistically significant increase in hypertension knowledge following the session (p = .005). Aim 3. Disseminate the program through the extension system and examine the process and statewide outcome measures of the program (T4 translational research) In its final year, DASH-Plus transitioned from research to a sustainable community health program within the UME. In April 2024, the project director trained educators for wider implementation. From May to December 2024, five educators delivered 45 in-person sessions across nine senior centers in five counties. The program has gained interest from Baltimore County Office of Quality Improvement, Golden Ring Co-op, and Lifebridge Health, University of Arizona and Virginia Extension, highlighting its potential for replication in other communities. With continued UME funding, DASH-Plus has sustained scaled-back fresh produce distribution and strengthened community engagement. The team is analyzing Phase 4 data and pursuing external funding to expand its impact, offering a scalable model for hypertension management nationwide.

Publications

  • Type: Conference Papers and Presentations Status: Accepted Year Published: 2022 Citation: Rosenstein R, Bush C, Dixon-Craven J, Habibi M, Henley S, Jackey B, Jeffrey J, Kim J, McCoy L, Patel D, Serio T, Song HJ. (2022). Feasibility of a synchronous virtual hypertension management program for community-dwelling older adults 55 and older through Extension. Journal of Nutrition Education and Behavior, 54(7S), https://www.jneb.org/article/S1499-4046(22)00167-1/pdf
  • Type: Conference Papers and Presentations Status: Accepted Year Published: 2023 Citation: Henley S, Habibi M, Jackey B, Patel D, Rosenstein, YR, Song HJ (2023). The Responses of an Older Adults Food Frequency Survey and Alignment with the Dietary Approaches to Stop Hypertension Plus. 2023 NEAFCS, Providence, RI. September 11-12, 2023
  • Type: Conference Papers and Presentations Status: Accepted Year Published: 2023 Citation: Rosenstein, YR, Song HJ (2023). Understanding perceptions, knowledge, and intention to follow a plant-based diet in hypertensive older adults. Journal of Nutrition Education and Behavior, 55(7), Supplement Page 92 https://doi.org/10.1016/j.jneb.2023.05.199
  • Type: Conference Papers and Presentations Status: Accepted Year Published: 2023 Citation: Song, HJ., Rosenstein, R., Bush, C., Cravens, J. D., Habibi, M., Henley, S., Jackey, B., McCoy, L., Patel, D., Serio, M., & Udahogora, M. (2023). Implementing an Integrated Hypertension Management Program for Community-Dwelling Older Adults Through Extension. Journal of Nutrition Education and Behavior, 55(7), 110. https://doi.org/10.1016/j.jneb.2023.05.233
  • Type: Conference Papers and Presentations Status: Accepted Year Published: 2024 Citation: Rosenstein, YR, Song HJ. (2024). Supporting hypertensive older adults in adopting a plant-based dietary pattern through a DASH diet-focused intervention (Oral presentation). Journal of Nutrition Education and Behavior, 56(8), Suppl. Page S76. https://doi.org/10.1016/j.jneb.2024.05.172
  • Type: Conference Papers and Presentations Status: Accepted Year Published: 2024 Citation: Song HJ. (2024). Promoting plant-based dietary patterns for chronic disease management in older adults: An update for Healthcare Practitioners. 2024 CUK-AAPINA International Nursing Conference, Seoul, Korea, May 23-24, 2024
  • Type: Conference Papers and Presentations Status: Accepted Year Published: 2024 Citation: Song, HJ., Rosenstein, R., Bush, C., Cravens, J. D., Habibi, M., Henley, S., Jackey, B., McCoy, L., Patel, D., Serio, M., & Udahogora, M. (2024). Examining the Effect of a DASH-Plus Intervention on Blood Pressure and Self-Care in Older Adults with Extension System Support. Journal of Nutrition Education and Behavior, 56(8), S92-S93. https://doi.org/10.1016/j.jneb.2024.05.207


Progress 01/01/23 to 12/31/23

Outputs
Target Audience:During this reporting period, the study team successfully expanded its reach by recruiting Carroll County, Maryland, as an additional site for the study. Two senior centers in the county agreed to participate. Older adults were recruited through announcements, marketing materials, posters, and in-person approaches at participating sites. The target audience met the following criteria: 1) aged 60 years and older, 2) regular attendance at senior centers, community sites, or Older Americans Act Nutrition Programs (at least three times per week), and 3) systolic blood pressure of 130-170 mmHg and/or diastolic blood pressure of 80-100 mmHg or taking hypertension medication. A total of 24 older adults from senior centers were successfully recruited for the study. Additionally, in 2023, the team conducted delayed interventions for the control groups recruited during the previous fiscal year, 2022. Approximately 74 participants from the control groups received the delayed intervention. To broaden the program's reach, the team also offered the delayed intervention to other interested seniors who had not previously participated in the research project. Consequently, a total of 107 older adults comprised the target audience during this reporting period. Changes/Problems: Nothing Reported What opportunities for training and professional development has the project provided?The continuous program implementation and evaluation activities during this reporting year have provided opportunities for graduate students to be actively engaged in the research project activities and to receive tailored mentoring throughout FY 2023. Their involvement has not only contributed to the project's progress but has also enriched their academic and practical experiences, fostering professional growth and skill development in a research setting. How have the results been disseminated to communities of interest?One of the participating sites proactively reached out to the research team to inquire about the project's progress and updates. In response, the team shared a concise program update summary with the site, keeping them informed about the latest developments and milestones achieved during the reporting period. This communication ensured that the participating site remained engaged and aware of the project's advancements, fostering a collaborative and transparent relationship. Further dissemination activities in FY 2024 to share the program updates with communities of interest will be planned. What do you plan to do during the next reporting period to accomplish the goals?For the next reporting period, the following major activities are planned: 1) To facilitate the translational process from the T3 phase to the T4 phase, the team is planning to submit an application for the University of Maryland Extension Signature Program. Achieving this designation requires meeting several criteria, including aligning with the extension's mission, addressing critical client needs, demonstrating replicability, and establishing public value. If approved, the DASH-Plus program will be further disseminated throughout the state and nationwide through extension programs. 2) Leveraging the revamped five-session educational materials and evaluation measures, the program will be disseminated statewide through the extension system, expanding its reach and impact. 3) The team will actively explore additional funding opportunities to ensure the program's long-term sustainability and continued growth. 4)Also, efforts will be directed towards preparing manuscripts and conference presentations, allowing for the dissemination of findings and insights gained throughout the project. 5)Additionally, the Principal Investigator will compile the final report, providing a comprehensive overview of the project's outcomes and accomplishments.

Impacts
What was accomplished under these goals? During FY 2023, the team successfully completed the T3 translational phase activities by continuously implementing the program at two additional study sites and collecting evaluation measures for the DASH-Plus intervention. Concurrently, the team proactively planned and prepared for the next T4 translational phase, aiming to disseminate and sustain the program through the extension system, ensuring long-term sustainability. Key milestones accomplished include the following: Continuous and further community outreach enabled the team to identify and recruit additional two senior centers in Carroll County, Maryland, expanding the program's reach. The team completed the successful delivery of the delayed intervention to control group participants. By providing the intervention to every participant, albeit at different time frames, the team demonstrated sensitivity to the community's needs and maintained trust. For instance, subsequent to the completion of the 24-week interviews with participants, the delayed intervention was scheduled at each control site. While priority was given to enrolling the DASH-Plus control group participants in the delayed intervention, the program was also open to individuals who were not initially part of the study but expressed interest in attending. To further support and encourage regular blood pressure monitoring practices at the control study sites, a few blood pressure monitors were donated to enable the establishment of on-site blood pressure measurement stations at the control group sites. This initiative aimed to promote regular monitoring and awareness of hypertension among the participants, complementing the educational components of the intervention. The project yielded four conference presentations and publications, contributing to the dissemination of findings and knowledge sharing. In preparation for the T4 translational phase, the team engaged in material compilation processes, developed new evaluation measures, and explored additional funding opportunities to support the program's sustainability and scalability. The team updated and finalized i) recruitment material, ii) an in-person series of 5-week education modules, iii) educational handouts for participants, iv) evaluation measures

Publications

  • Type: Conference Papers and Presentations Status: Published Year Published: 2023 Citation: Song, HJ., Rosenstein, YR., Bush, C., Cravens, J., Habibi, M., Henley, S., Jackey, B., McCoy, L., Patel, D., Serio, T., Udahogora, M., & Kim, JH. (2023). Implementing an Integrated Hypertension Management Program for Community Dwelling Older Adults Through Extension. Journal of Nutrition Education and Behavior. Washington, DC. 55(7S), 110. https://doi.org/10.1016/j.jneb.2023.05.233
  • Type: Conference Papers and Presentations Status: Published Year Published: 2023 Citation: Rosenstein, YR, Song HJ. Understanding perceptions, knowledge, and intention to follow a plant-based diet in hypertensive older adults. 2023 SNEB, Washington DC. July 20-23. https://doi.org/10.1016/j.jneb.2023.05.199
  • Type: Conference Papers and Presentations Status: Accepted Year Published: 2023 Citation: Henley, S.C., Habibi, M., Jackey, B., Patel, D., Rosenstein, R., & Song, H.J. (2023). The Responses of an Older Adults Food Frequency Survey and Alignment with The Dietary Approaches to Stop Hypertension Plus. National Extension Association of Family and Consumer Sciences Annual Session, Providence, Rhode Island, September 11-12, 2023.
  • Type: Conference Papers and Presentations Status: Accepted Year Published: 2023 Citation: Song, HJ. (2023). Effects of an Integrated System Approach on Hypertension Management in Community-Dwelling Older Adults. 2023 Society for Nutrition Education and Behavior, Washington, DC. (Invited)


Progress 01/01/22 to 12/31/22

Outputs
Target Audience:From the beginning of year 2, the team reached out to potential target counties and target sites (senior centers, community sites, congregate meal sites, etc)in Maryland (MD). A total of 14 senior centers or community sites in seven Maryland counties agreed to participate in the program. Participating counties include Allegany, Montgomery, Baltimore, Cecil, Kent, Queen Anne's, and Wicomico counties. Using a quasi-experimental study design, two sitesfrom each county were selected and assigned to intervention or control sites except Baltimore County. In Baltimore County, four sites were recruited (two intervention sites and two control sites). Once participating sites were selected, the team recruited older adults through announcements, marketing flyers, posters, and in-person approaches. The target audience was 1) 60 years of age and older, 2) attend senior centers, other community sites, or Older Americans Acts Nutrition Program regularly (at least three times per week), 3) has a systolic blood pressure of 130-170 mm Hg and/or diastolic blood pressure of 80-100 mg Hg or on hypertension medication. A total of 188hypertensive older adults enrolled in the studyand completed baseline surveys. Also, during this reporting period, 168completed 8-week intermediate surveys. Some seniors passed away or dropped out of the study due to early dementia, or personal issues. Changes/Problems:Changes in the approved protocol Originally, the research team planned to employ a cluster randomization method to recruit study sites, and participants and test the effectiveness of proposed intervention approaches. In 2022, most states across the country including Maryland had been dropping COVID-related regulations since the lockdown in 2019. However, many potential community sites for the project were still not fully functioning and older adults attending community sites and senior centers have not yet completely resumed their daily activities in community sites. Further, when the team planned recruitment, it could not be guaranteed that COVID regulation would be completely lifted for human subject studies throughout this reporting period and there might still be a chance to go back into full or partial lockdown again. Considering the fluid situation in 2022, the team reached a consensus that a quasi-experimental approach might be a better option to recruit sites and study participants and retain them at this point. This request had been submitted and approved by the funder. Major issues on expenditure Major problems that have a significant impact on the expenditure include produce delivery cost and the hourly pay rate for part-time student data collectors Initially, the team allocated $ 7 for one weekly produce basket per participant and budgeted $ 20,160 for 24-week produce deliveries for the intervention participants (n=120) for 24 weeks. Around the middle of this reporting period, produce delivery vendors have understandably raised concerns about the rising gas prices and produce deliveries due to economic inflation, especially since our order for participants wascustomized and smaller than their usual minimum dollar amount to accommodate the study and our participants. Due to these reasons, per basket price had to be adjusted and itranged from $ 10-14 depending on the location of study sites and vendorswhich significantly affected expenditure. Economic inflation also negatively affected hiring part-time students. Initially,a $12 hourly payment for undergraduate-level data collectors was allocated but this rate wasnot feasible for them to participate in the data collection. So, it was raised to $ 18 per hour. What opportunities for training and professional development has the project provided?In March 2022, the project provided a half-day training to extension educators in the team before the intervention program was implemented to go over the study protocol, modules, logistics, etc. In April 2022, additional one-hour booster training was offered to the educators for the Wellness program training. Also, several 2-3 hour data collection training had been offered to students' data collectors throughout FY 2022. How have the results been disseminated to communities of interest? Nothing Reported What do you plan to do during the next reporting period to accomplish the goals?The following highlights major activities to do during the next reporting period. The team is communicating with 1-2 potential community partners in Frederic and Prince George Counties in MD. If they agree, 1 or 2 additional counties (2-4 study sites) will be recruited. If additional sites are recruited, the program will be implemented and evaluated by Fall 2023. Data collection will be continued in existing and new sites. The data entry will be continued. By the end of the next reporting period, the data set will be cleaned and might be ready for data analysis. At least baseline data will be analyzed and prepared for conferences. Delayed intervention at the control sites will be offered. Exit interviews with participating site directors and peer supporters will be conducted The team will compile a tool kit to plan dissemination for the translational phase 4 program The team will prepare manuscripts, and conference presentations and the PI will also prepare the final report.

Impacts
What was accomplished under these goals? The following activities and experiments have been accomplished during this reporting period to fulfill three functions of the agricultural knowledge system (education, research, and extension). Education) One of the main purposes of the study is to integrate this research project into the education system to train and foster human capital by working with an undergraduate dietetics program and an extension internship course. In Fall 2022 (September - December 2022), junior and senior dietetic students taking a NFSC 350, Food Service Operation class (~ 36 students) which is a required course for dietetic students had hypertension-specific experiential learning opportunities by learning hypertension management and control among older adults, non-pharmacological lifestyle approaches, DASH eating, etc. Also, in the Food Service Operation lab, dietetic students had been involved in a variety of practical activities including menu planning, recipe testing, and diet analysis related to hypertension management. In particular, the hypertension-friendly recipe booklet was thoroughly reviewed and finalized for printing with Dr. Udahogora's help during this reporting period. And NFSC 350 students added and tested additional hypertension-friendly recipes. Research & Extension) The team was able to fully implement the project in communities this year and the main activities and accomplishments include having a training workshop for the team, recruiting study sites, and participants, collecting data, and building collaborative partnerships with local and national produce delivery companies including Hungry Harvest, Garret Growers, and Teddy Bear Fresh. In early spring 2022, the team had a half-day training workshop to plan recruitment and program logistics. To maximize recruitment efficiency and minimize any possible confusion for community partners, two separate recruitment flyers (one for the intervention and one for the control), study flow, FAQ, and posters were developed. Also, a pool of part-time student data collectors (about 16 students) was hired and trained. The team also selected the list of curricula that would be offered to the control sites to make the control sites receive a comparable amount of exposure. Non-hypertension-related programs including 'training on talking with your doctor and health professional', 'training on green cleaning', 'food safety', and 'kitchen kaizen' were selected to be offered to the control group (Wellness program). A few extension educators updated and finalized the materials and all extension educators received about 1-2 hours of training per curriculum before the program started. From May 2022, the program has been offered to participating sites. A total of seven counties in MD participated in the program. The intervention group participants have received a series of 8-week DASH+ education, weekly produce delivery for 24 weeks, and a blood pressure monitor. The control group participants also received a series of bi-weekly Wellness education. When the control group participants attend a class, they received a small promotional item for each class (~ $5 worth of item). Atotal of 188 completed the baseline survey, and about 90% of participants (n=168) completed 8-week, intermediate survey. Currently, data entry and data mining are in process. The team is in the process of conference presentation using the baseline data collected during this reporting period. The followings are the summary of accomplishments achieved during this reporting period. The team developedand/or finalized1) recruitment materials for participating sites and participants,2) in-person 8-week education modules,3) in-person 8-weekfacilitator manuals The evaluation instruments and forms were developed and/or finalized. (e.g., participant questionnaire (baseline, 8 weeks, and 24 weeks), attendance log, produce pickup log, individual blood pressure monitoring log, exit survey, etc) The team has built collaborative partnerships with three produce delivery service companies in central, northwestern, and eastern Marylandand the program logistics with the producedelivery companies were finalized. A group of student data collectors was hired and trained. The team has collaborated with seven counties in MD and recruited a total of 14 study sites, peer supporters (intervention sites only), and participants (n=188) The extension educators implemented an in-person program (DASH+) at seven intervention sites(i) an 8-week DASH-plus education (Dietary Approaches to Stop Hypertension diet with exercise and HTN self-care skills), ii) weekly produce delivery to increase produce accessibility and availability and iii) self-measured blood pressure (BP) monitoring. The extension educators implemented an in-person program (Wellness+) at seven control sites. The data collection (baseline, intermediate, and post-intervention, process evaluation) has been conducted The manuscripts (based on Year 1 results) are in progress.

Publications


    Progress 01/01/21 to 12/31/21

    Outputs
    Target Audience:Due to the continuous COVID-19 lockdown, no in-person research could be commenced during this reporting period, (Year1). In-person human subject research was not permitted until the research restrictions were lifted or approval was obtained from the Department Chair, Dean, and the Vice President for Research at the University of Maryland College Park. Instead of holding up an entire research process, the team proactively pilot-tested an 8-week DASH-Plus education curriculum virtually by offering synchronous online hypertension education to hypertensive older adults in Maryland. The target during this reporting period was older adults 55 years of age and older. Program participants were recruited using marketing flyers, and word of mouth. Also, the team promoted the program on University of Maryland Extension social media pages to recruit potential participants. To be eligible, participants must be 55 years of age and older, live in Maryland, and has systolic blood pressure (SBP) of 130-170 mm Hg and/or diastolic blood pressure (DBP) of 80-100 mm Hg or HTN medication. For the Year 1 pilot trial, there was no screening process. Instead, participants who self-identified as having hypertension were eligible to participate in the program. The purpose of the Year 1 trial was to test the feasibility of synchronous virtual education by examining how well the education materials and synchronous format would be accepted by older adults, whether there were any issues related to program logistics, how effective this education program was, etc. The maximum enrollment number was estimated based on previous experience and empirical data. On average, 6-7 older adults attend a virtual session in other extension programs. For the present study, a total of 352 older adults registered for the online sessions, and 74 actually attended at least one session out of eight sessions. Changes/Problems:Major problems in approach at year 1 (2021) were caused by Covid-19. Despite unprecedented challenges, the team efficiently developed education materials for synchronous, online education, and successfully implemented and evaluated the modules virtually. The virtual education pilot-tested is a great 'add-on' component rather than changing the project plan. It will not significantly affect the overall project timeline. Given the project outcomes, the impact of virtual hypertension education, and its feasibility, the team can consider developing a new online education platform for older adults to provide the DASH-Plus or similar chronic disease management programs via synchronous online format after the COVID-19 pandemic. For the next reporting period (2022), the PD submitted a written letter to request a USDA program leader's review and approval in changing the study design of the project. Originally, the research team has planned to employ a cluster randomization method to recruit study sites, and participants and test the effectiveness of proposed intervention approaches. Since the lockdown in 2019, most states across the country including Maryland are dropping COVID-related regulations. However, many potential community sites for the project are still not fully functioning and older adults attending community sites and senior centers have not yet completely resumed their daily activities in community sites. Considering the current fluid situation, the team reaches a consensus that a quasi-experimental approach might be a better option to recruit sites and study participants and retain them at this point. What opportunities for training and professional development has the project provided?Integrating the research project into a structured undergraduate dietetic course and an Extension internship course has offered great experiential training opportunities for students. Also, volunteer and/or internship opportunities were given to a small group of dietetic students if they were interested in being involved in additional scholarly activities. For Family and Consumer Science extension educators in the team, a half-day training workshop was held in May 2021. A nurse practitioner who is a consultant for the research team offered a session about "Pharmacological management of hypertension" to train the project team members. Also, at the end of this project year, the team prepared a conference abstract to attend the 2022 professional development conference. How have the results been disseminated to communities of interest? Nothing Reported What do you plan to do during the next reporting period to accomplish the goals?The following highlights major activities to do during the next reporting period. Update and finalize 1) recruitment materials for participating sites and participants, 2) in-person 8-week education modules, 3) 8-week facilitator manuals Finalize evaluation instruments and forms (e.g., participant questionnaire, attendance log, individual blood pressure monitoring log, exit survey, etc) Finalize logistics with an online produce delivery service company Recruit and train data collectors Recruit study sites, peer supporters (intervention sites only), and participants (n=240) Implement an in-person program (i) an 8-week DASH-plus education (Dietary Approaches to Stop Hypertension diet with exercise and HTN self-care skills), ii) online produce delivery to increase produce accessibility and availability and iii) self-measured blood pressure (BP) monitoring.) Conduct data collection (baseline, intermediate and post-intervention, process evaluation, exit survey) Prepare and submit conference abstracts, manuscripts (based on Year 1 results)

    Impacts
    What was accomplished under these goals? The following activities and experiments have been accomplished during this reporting period to fulfill three functions of the agricultural knowledge system (education, research, and extension). Also, it presents key study outcomes and summary statistics this year. Education: One of the main purposes of the study is to integrate this research project into the education system to train and foster human capital by working with an undergraduate dietetics program and an extension internship course. A "Food Service Operations" course (NFSC 350) offered to upper-level undergraduate dietetic students at the University of Maryland, College Park has two components, a lecture portion, and a laboratory portion. The combination of the lecture and laboratory components allow students to obtain the necessary knowledge on food quantity production, purchasing in food service operation and preparing well-balanced meals for a variety of population and then apply this knowledge through hands-on experience in the food service lab. In Fall 2021 (September - December 2021), junior and senior dietetic students taking a ' Food Service Operation' class (~ 36 students) had hypertension-specific experiential learning opportunities by learning hypertension management and control among older adults, non-pharmacological lifestyle approaches, DASH eating, etc. Also, in the Food Service Operation lab, dietetic students had been involved in a variety of practical activities including menu planning, recipe testing, and diet analysis focusing on hypertensive older adults. Further, students were able to understand how their study outcomes were connected to the actual extension program. The core knowledge and competencies required for an entry-level registered dietician include the integration of scientific information and translation of research into practice. The role of research in nutrition and dietetics has been an integral part of dietetic practice, but there have been limited studies that demonstrate how to research relevant opportunities have been provided to dietetic students to equip them for future professions ensuring graduates are competent to do research in practice. Currently, a small sub-group of dietetic students has been working on a manuscript to report how a research project could be integrated into a classroom setting, scientific and evidence information could be translated into practice, and what core knowledge and competencies are required for an entry-level registered dietician can be achieved by this experience. In Spring and Fall 2021 (Jan- December 2021), this project was integrated into the University of Maryland Extension Internship course. Once extension interns (one intern per semester) completed basic extension-related coursework and they worked with a research team by assisting program material development, data analysis, etc. Research & Extension: Originally, the project was planned to be offered in an in-person format. Due to the COVID-19 lockdown, all potential community sites for recruitment were closed and it was not feasible to plan and prepare any in-person program activities. To maximize the benefits of program implementation while being adapted to the COVID-19 environment, the team decided to develop an online version of 8-week DASH-Plus education sessions (8 education modules, facilitator manuals, and pre and post-survey for each module) along with supplementary materials including hypertension friendly cooking videos, interactive online activities, etc. The team successfully transitioned 8-week education modules and facilitator manuals to be delivered electronically and pilot-tested the feasibility of a synchronous, virtual hypertension management program, and assessed its efficacy in improving mediators of HTN-related behavior change. In 2021, the study was a non-controlled, pre-post experimental intervention. The virtual synchronous hypertension program was advertised and available via Zoom for three different time frames from July - October 2021. Reflecting on the reality of community participation for this pilot trial, it was not mandatory for participants to attend all eight sessions. A total of 74 primarily hypertensive older adults participated in the program and completed online pre and post-surveys after each session. The results showed increases in self-efficacy for desirable behaviors to manage hypertension in the Grains (p=.012), Fruits &Vegetables (FV) (p=.024), Meats (p=.035), and Fats & Sweets (p=.034) sessions. Also, the perceived benefits of modifying eating patterns were improved in Sodium (p=.004), Grains (p=.001), and Meats (p=.034) sessions. Further, participants showed improved readiness to change for the Grains (p=.011) and FV (p=.046) sessions. The study findings support that a synchronous virtual hypertension education program is feasible and effective in improving key constructs related to hypertension including self-efficacy for desirable behaviors to manage hypertension, perceived benefits of modifying eating patterns, readiness to change behavior, etc. Also, collaborative partnership with Extension is a promising approach to ensure program sustainability. There had been several major barriers (e.g., technical issues, logistics, data collection, etc), but using a synchronous, virtual format for older adults to address hypertension through the UME system was a feasible approach. This prelim work proposes strong potential to develop a future virtual program for older adults, disseminate it throughout the state, replicate it in similar settings in other states, and possibly address healthy disparity gaps.

    Publications

    • Type: Conference Papers and Presentations Status: Accepted Year Published: 2022 Citation: Rosenstein R, Bush C, Dixon-Craven J, Habibi M, Henley S, Jackey B, Jeffrey J, Kim J, McCoy L, Patel D, Serio T, Song HJ. Feasibility of a synchronous virtual hypertension management program for community-dwelling older adults 55 and older through Extension. July 29- August 1, 2022. Atlanta, Georgia, USA