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1.  Psychometric properties of a brief measure of autonomy support in breast cancer patients 
The Health Care Climate Questionnaire measures patient perceptions of their clinician’s autonomy supportive communication. We sought to evaluate the psychometric properties of a modified brief version of the Health Care Climate Questionnaire (mHCCQ) adapted for breast cancer patients.
We surveyed 235 women aged 20–79 diagnosed with breast cancer within the previous 18 months at two cancer specialty centers using a print questionnaire. Patients completed the mHCCQ for their surgeon, medical oncologist, and radiation oncologist separately, as well as the overall treatment experience. Exploratory factor analysis (EFA) using principal components was used to explore the factor structure.
One hundred sixty out of 235 (68.1 %) women completed the survey. Mean age was 57 years and time since diagnosis was 12.6 months. For surgeon, medical oncologist, and radiation oncologist ratings separately, as well as overall treatment, women rated 6 dimensions of perceived physician autonomy support. Exploratory factor analysis indicated a single factor solution for each clinician type and for the overall experience. Further, all six items were retained in each clinician subscore. Internal consistency was 0.93, 0.94, 0.97, and 0.92 for the overall, surgeon, medical oncologist, and radiation oncologist scales, respectively. Hierarchical factor analysis demonstrated that a summary score of the overall treatment experience accounts for only 52 % of the total variance observed in ratings of autonomy support for the three provider types.
These results describe the first use of the mHCCQ in cancer patients. Ratings of the overall treatment experience account for only half of the variance in ratings of autonomy support, suggesting that patients perceive and report differences in communication across provider types. Future research is needed to evaluate the relationship between physician communication practices and the quality of decision making, as well as other outcomes among cancer patients.
PMCID: PMC4496811  PMID: 26155944
Autonomy support; Breast cancer; Health Care Climate Questionnaire
2.  Adaptation of a Counseling Intervention to Address Multiple Cancer Risk Factors Among Overweight/Obese Latino Smokers 
More than 60% of cancer-related deaths in the United States are attributable to tobacco use, poor nutrition, and physical inactivity, and these risk factors tend to cluster together. Thus, strategies for cancer risk reduction would benefit from addressing multiple health risk behaviors. We adapted an evidence-based intervention grounded in social cognitive theory and principles of motivational interviewing originally developed for smoking cessation to also address physical activity and fruit/vegetable consumption among Latinos exhibiting multiple health risk behaviors. Literature reviews, focus groups, expert consultation, pretesting, and pilot testing were used to inform adaptation decisions. We identified common mechanisms underlying change in smoking, physical activity, and diet used as treatment targets; identified practical models of patient-centered cross-cultural service provision; and identified that family preferences and support as particularly strong concerns among the priority population. Adaptations made to the original intervention are described. The current study is a practical example of how an intervention can be adapted to maximize relevance and acceptability and also maintain the core elements of the original evidence-based intervention. The intervention has significant potential to influence cancer prevention efforts among Latinos in the United States and is being evaluated in a sample of 400 Latino overweight/obese smokers.
PMCID: PMC4467573  PMID: 25527143
adaptation; intervention; Latinos; health risk behavior
3.  Unplanned Quitting in a Triethnic Sample of U.S. Smokers 
Nicotine & Tobacco Research  2014;16(6):759-765.
Smokers who report quitting without prior planning have been shown to report longer abstinence compared with those who planned. Little is known about unplanned quitting (UQ) among U.S. smokers, minorities, or nondaily and light smokers.
Using an online panel, we recruited equal numbers of Black, White, and Latino nondaily, light daily, and moderate/heavy daily smokers. Of the 1,127 who reported a past-year quit attempt, we queried whether it was planned and the maximum number of days abstinent.
Overall, 38% reported that their last quit attempt was unplanned. The impact of planned versus unplanned quitting interacted with smoking level and race. Among White moderate/heavy smokers, mean days abstinent was 99 for those who reported an unplanned quit attempt compared with 60 days for those who reported a planned attempt (p = .02). Among Black moderate/heavy smokers, the mean days abstinent was higher among those whose last attempt was planned, 92 days, compared with 56 days among those whose last attempt was unplanned (p = .09). The pattern among Latinos resembled Whites but was not significant. Results remained after adjusting for confounds such as age, gender, education, income, time to first cigarette, and menthol use. There were no significant differences in abstinence by quit type for light or nondaily smokers.
Future studies are needed to elucidate why UQ appears to have differential effectiveness across racial/ethnic groups and different levels of cigarette use. Research examining the impact of UQ on long-term quitting, which is not addressed here, is needed.
PMCID: PMC4064007  PMID: 24420329
4.  Racial/ethnic differences in clinical trial enrollment, refusal rates, ineligibility, and reasons for decline among patients at sites in the National Cancer Institute's Community Cancer Centers Program 
Cancer  2013;120(6):877-884.
This study examined racial/ethnic differences among patients in clinical trial (CT) enrollment, refusal rates, ineligibility, and desire to participate in research within the National Cancer Institute's Community Cancer Centers Program (NCCCP) Clinical Trial Screening and Accrual Log.
Data from 4509 log entries were evaluated in this study. Four logistic regression models were run using physical/medical conditions, enrollment into a CT, patient eligible but declined a CT, and no desire to participate in research as dependent variables.
Age ≥ 65 (OR=1.51, CI: 1.28 -1.79), males (OR=2.28, CI: 1.92 – 2.71), and non-Hispanic black race (OR=1.53, CI: 1.2 – 1.96) were significantly associated with more physical/medical conditions. Age ≥ 65 was significantly associated with lower CT enrollment (OR=0.83, CI: 0.7 - 0.98). Males (OR=0.78, CI: 0.65 -0.94) and a higher grade level score for consent form readability (OR=0.9, CI: 0.83 - 0.97) were significantly associated with lower refusal rates. Consent page length ≥ 20 was significantly associated with lower odds of “no desire to participate in research” among CT decliners (OR=0.75, CI: 0.58 – 0.98).
: There were no racial/ethnic differences in CT enrollment, refusal rates, or “no desire to participate in research” as the reason given for CT refusal. Higher odds of physical/medical conditions were associated with older age, males, and non-Hispanic blacks. Better management of physical/medical conditions before and during treatment may increase the pool of eligible patients for CTs. Future work should examine the role of co-morbidities, sex, age, and consent form characteristics on CT participation.
PMCID: PMC3947654  PMID: 24327389
Racial/ethnic; African Americans; Hispanic; Minorities; Clinical Trials; Medical Research; Cancer
5.  Development and Implementation of the National Cancer Institute’s Food Attitudes and Behaviors Survey to Assess Correlates of Fruit and Vegetable Intake in Adults 
PLoS ONE  2015;10(2):e0115017.
Low fruit and vegetable (FV) intake is a leading risk factor for chronic disease globally as well as in the United States. Much of the population does not consume the recommended servings of FV daily. This paper describes the development of psychosocial measures of FV intake for inclusion in the U.S. National Cancer Institute’s 2007 Food Attitudes and Behaviors Survey.
This was a cross-sectional study among 3,397 adults from the United States.
Scales included conventional constructs shown to be correlated with fruit and vegetable intake (FVI) in prior studies (e.g., self-efficacy, social support), and novel constructs that have been measured in few- to- no studies (e.g., views on vegetarianism, neophobia). FVI was assessed with an eight-item screener. Exploratory factor analysis, Cronbach’s alpha, and regression analyses were conducted.
Psychosocial scales with Cronbach’s alpha ≥0.68 were self-efficacy, social support, perceived barriers and benefits of eating FVs, views on vegetarianism, autonomous and controlled motivation, and preference for FVs. Conventional scales that were associated (p<0.05) with FVI were self-efficacy, social support, and perceived barriers to eating FVs. Novel scales that were associated (p<0.05) with FVI were autonomous motivation, and preference for vegetables. Other single items that were associated (p<0.05) with FVI included knowledge of FV recommendations, FVI “while growing up”, and daily water consumption.
These findings may inform future behavioral interventions as well as further exploration of other potential factors to promote and support FVI.
PMCID: PMC4338082  PMID: 25706120
6.  Validation of PIN 3 physical activity survey in low-income overweight and obese young mothers 
BMC Public Health  2015;15:121.
Existing physical activity surveys have not been validated for use with low-income overweight and obese young mothers. This study aimed to validate the Pregnancy Infection and Nutrition 3 (PIN3) physical activity survey and to explore whether its validity varied by race/ethnicity and body mass index (BMI) category when including or excluding child and adult care activities in the target population.
Participants were recruited from the Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) and were asked to fill out the PIN3 survey and wear an Actigraph accelerometer. Validity was assessed (N = 42) using Spearman correlation coefficient.
Regardless of inclusion or exclusion of child and adult care activity, the PIN3 survey showed evidence of validity for moderate (correlation coefficients 0.33 [p = 0.03]; 0.40 [p = 0.08]) but not vigorous (−0.01 [p = 0.91]; −0.06 [p = 0.69]) physical activity. The mean minutes per week spent in moderate, vigorous and moderate-vigorous physical activity measured by the PIN3 were substantially higher than when measured by accelerometer, for example, 588 (PIN3) versus 148 (accelerometer) minutes per week. Also, correlations between self-reported and objective monitored activity varied substantially by race/ethnicity and BMI category, for example, 0.29 (p = 0.18) for overweight women versus 0.57 (p = 0.007) for obese women; 0.27 (p = 0.20) for African American versus 0.66 (p = 0.001) for white.
The PIN3 survey may be adequate for many applications where quick and practical assessments are needed for moderate physical activity data in low-income overweight and obese young mothers. The substantial differences in mean minutes per week between the PIN3 and accelerometer may be due to over-reported physical activity by the study participants.
Trial registration
Clinical Trials Number: NCT01839708
PMCID: PMC4331310  PMID: 25885482
Validity; Physical activity survey; Low-income women
7.  Disparities in Age-Appropriate Child Passenger Restraint Use Among Children Aged 1 to 12 Years 
Pediatrics  2014;133(2):262-271.
Observed racial disparities in child safety seat use have not accounted for socioeconomic factors. We hypothesized that racial differences in age-appropriate restraint use would be modified by socioeconomic status and child passenger safety information sources.
A 2-site, cross-sectional tablet-based survey of parents seeking emergency care for their 1- to 12-year-old child was conducted between October 2011 and May 2012. Parents provided self-report of child passenger safety practices, demographic characteristics, and information sources. Direct observation of restraint use was conducted in a subset of children at emergency department discharge. Age-appropriate restraint use was defined by Michigan law.
Of the 744 eligible parents, 669 agreed to participate and 601 provided complete responses to key variables. White parents reported higher use of car seats for 1- to 3-year-olds and booster seats for 4- to 7-year-olds compared with nonwhite parents. Regardless of race, <30% of 8- to 12-year-old children who were ≤4 feet, 9 inches tall used a booster seat. White parents had higher adjusted odds (3.86, 95% confidence interval 2.27–6.57) of reporting age-appropriate restraint use compared with nonwhite parents, controlling for education, income, information sources, and site. There was substantial agreement (82.6%, κ = 0.74) between parent report of their child’s usual restraint and the observed restraint at emergency department discharge.
Efforts should be directed at eliminating racial disparities in age-appropriate child passenger restraint use for children <8 years. Booster seat use, seat belt use, and rear seating represent opportunities to improve child passenger safety practices among older children.
PMCID: PMC3904276  PMID: 24420814
child restraint systems; survey; health behavior; socioeconomic factors
8.  Development and psychometric properties of a brief measure of subjective decision quality for breast cancer treatment 
Breast cancer patients face several preference-sensitive treatment decisions. Feelings such as regret or having had inadequate information about these decisions can significantly alter patient perceptions of recovery and recurrence. Numerous objective measures of decision quality (e.g., knowledge assessments, values concordance measures) have been developed; there are far fewer measures of subjective decision quality and little consensus regarding how the construct should be assessed. The current study explores the psychometric properties of a new subjective quality decision measure for breast cancer treatment that could be used for other preference sensitive decisions.
320 women aged 20–79 diagnosed with AJCC stage 0 – III breast cancer were surveyed at two cancer specialty centers. Decision quality was assessed with single items representing six dimensions: regret, satisfaction, and fit as well as perceived adequacy of information, time, and involvement. Women rated decision quality for their overall treatment experience and surgery, chemotherapy, and radiation decisions separately. Principle components was used to explore factor structure. After scales were formed, internal consistency was computed using Cronbach’s alpha. The association of each of the four final scales with patient characteristics scores was examined by Pearson correlation.
For overall breast cancer treatment as well as surgery, chemotherapy, and radiation decisions, the six items yielded a single factor solution. Factor loadings of the six decision items were all above .45 across the overall and treatment-specific scales, with the exception of “Right for You” for chemotherapy and radiation. Internal consistency was 0.77, 0.85, 0.82, and 0.78 for the overall, surgery, chemotherapy, and radiation decision quality scales, respectively.
Our measure of subjective appraisal of breast cancer treatment decisions includes 5 related elements; regret and satisfaction as well as perceived adequacy of information, time, and involvement. Future research is needed to establish norms for the measure as is further psychometric testing, particularly to examine how it is associated with outcomes such as quality of life, psychological coping and objective decision quality.
PMCID: PMC4272518  PMID: 25476986
Breast cancer; Oncology; Decision making; Decision quality; Decision satisfaction; Scale development; Psychometric testing
9.  A Diabetes Peer Support Intervention That Improved Glycemic Control: Mediators and Moderators of Intervention Effectiveness 
Chronic illness  2013;9(4):10.1177/1742395313476522.
In a randomized trial, a guided diabetes peer-support intervention improved glycemic control (A1c), with a difference in A1c change between groups of 0.58% (P = 0.004). The current study examined whether improvements in insulin uptake and perceived diabetes social support (DSS) mediated the intervention’s impact on A1c. We also examined potential moderation by patients’ health literacy, DSS, or diabetes distress.
We conducted secondary analyses for 212 type 2 diabetes patients participating in the trial using accepted methods for testing effect mediation and moderation.
Roughly half (49%, 95% CI: 3%–80%) of the A1c effect was mediated by increased insulin use, while changes in DSS had a negligible impact. A1c impacts varied across subgroups defined by baseline DSS and functional health literacy (both p<0.01). The intervention was particularly beneficial among patients with low baseline diabetes support or literacy levels. The intervention had a greater impact on A1c among patients with more frequent engagement in peer-support calls (p<0.01).
Patients receiving increased peer support had improved glycemic control largely due to their greater likelihood of initiating insulin. Greater intervention engagement was associated with stronger effects. The intervention had its greatest benefits among patients with low support or poorer health literacy.
PMCID: PMC3830685  PMID: 23585636
self-management; behavior change; peer-support
10.  A Randomized Trial of an Avatar-Hosted Multiple Behavior Change Intervention for Young Adult Smokers 
Young adulthood is a critical transition period for the development of health behaviors. We present here the results of a randomized controlled trial of an online avatar-hosted personal health makeover program designed for young adult smokers.
We conducted a three-group randomized trial comparing delivery of general lifestyle content (Tx1), personally tailored health information (Tx2), and personally tailored health information plus online video–based peer coaching (Tx3) as part of a 6-week online health program. Participants were asked to set weekly goals around eating breakfast, exercise, alcohol use, and cigarette smoking. Eligibility criteria included age (18–30 years) and smoking status (any cigarette use in the previous 30 days). The primary outcome was self-reported 30-day abstinence measured 12 weeks postenrollment.
Participant (n = 1698) characteristics were balanced across the groups (72% women, mean age 24, 26% nonwhite, 32% high school education or less, and 50% daily smokers). Considering intention to treat, 30-day smoking abstinence rates were statistically significantly higher in the intervention groups (Tx1 = 11%, Tx2 = 23%, Tx3 = 31%, P < .001). Participants in the intervention groups were also more likely to reduce their number of days spent on binge drinking and increase their number of days eating breakfast and exercising. Overall, intervention group participants were much more likely to make positive changes in at least three or four of the target behaviors (Tx1 = 19%, Tx2 = 39%, Tx3 = 41%, P < .001).
This online avatar-hosted personal health makeover “show” increased smoking abstinence and induced positive changes in multiple related health behaviors. Addition of the online video–based peer coaching further improved behavioral outcomes.
PMCID: PMC3881995  PMID: 24395994
11.  Motivational Interviewing to Enhance Nicotine Patch Treatment for Smoking Cessation among Homeless Smokers: A Randomized Controlled Trial 
Addiction (Abingdon, England)  2013;108(6):1136-1144.
To assess the effects of adding motivational interviewing (MI) counseling to nicotine patch for smoking cessation among homeless smokers.
Two-group randomized controlled trial with 26-week follow-up.
430 homeless smokers from emergency shelters and transitional housing units in Minneapolis/St. Paul, Minnesota, USA.
All participants received 8-week treatment of 21mg nicotine patch. In addition, participants in the intervention group received six individual sessions of MI counseling which aimed to increase adherence to nicotine patch and to motivate cessation. Participants in the Standard Care control group received one session of brief advice to quit smoking. Primary outcome was seven-day abstinence from cigarette smoking at 26 weeks as validated by exhaled carbon monoxide and salivary cotinine.
Using intention-to-treat analysis, verified seven-day abstinence rate at week 26 for the intervention group was non-significantly higher than for the control group (9.3% vs. 5.6%, p=0.15). Among participants that did not quit smoking, reduction in number of cigarettes from baseline to week 26 was equally high in both study groups (−13.7 ±11.9 for MI vs. −13.5 ±16.2 for Standard Care).
Adding motivational interviewing counseling to nicotine patch did not significantly increase smoking rate at 26-week follow-up for homeless smokers.
PMCID: PMC3651796  PMID: 23510102
12.  Clinical Trial Awareness Among Racial/Ethnic Minorities in HINTS 2007: Sociodemographic, Attitudinal, and Knowledge Correlates 
Journal of health communication  2010;15(0 3):92-101.
The purpose of this study was (1) to examine the association of race/ethnicity on clinical trial awareness, controlling for several sociodemographic, attitudinal, and knowledge variables, and (2) to inform future communication campaigns to increase clinical trial awareness and participation. Secondary analysis was conducted among 6,754 Hispanic, Black, and White adult respondents to the National Cancer Institute’s 2007 Health Information National Trends Survey (HINTS). The dependent variable was awareness of clinical trials. Logistic regression was used to examine possible correlates of clinical trial awareness including sociodemographics, trust of sources of health information, beliefs about safety of health information, family/personal history of cancer, health seeking information, and awareness of three health agencies. Compared with Whites, Blacks and Hispanics were significantly less likely to have heard of a clinical trial. Other significant correlates of clinical trial awareness included education, income, belief that health information is safely guarded, family history of cancer, awareness of the Centers for Disease control, trust of health information from the Internet and charitable organizations, and distrust of health information from religious institutions. Blacks and Hispanics are significantly less aware of clinical trials. Campaigns that exploit unique beliefs and delivery channels for racial/ethnic subgroups should be considered.
PMCID: PMC4013828  PMID: 21154086
13.  A community based prevention of weight gain intervention (Mothers In Motion) among young low-income overweight and obese mothers: design and rationale 
BMC Public Health  2014;14:280.
Over 45% of American women 20–39 years old are at risk for type 2 diabetes, cardiovascular disease, and other health conditions because they are overweight or obese. The prevalence of overweight and obesity is disproportionately high among low-income women. This paper describes the study design and rationale of a community based intervention (Mothers In Motion, MIM) aimed to prevent weight gain among low-income overweight and obese mothers18-39 years old by promoting stress management, healthy eating, and physical activity.
Peer recruiters approach participants from 5 Special Supplemental Nutrition Program for Women, Infants, and Children (WIC) in Michigan. The MIM delivers theory-based, culturally-sensitive intervention messages via a combination of DVDs and peer support group teleconferences (PSGTs). The DVD features African American and white overweight and obese WIC mothers who participated in a healthy lifestyle intervention patterned after MIM. The PSGTs are led by paraprofessionals from Michigan State University Extension and WIC providers in Michigan who are trained in motivational interviewing and group facilitation skills. Participants are randomly assigned to an intervention (n = 350) or comparison group (n = 175). The intervention group receives a 16-week intervention on a weekly or bi-weekly basis. Participants are asked to watch 10 MIM DVD chapters at home and join 10 PSGT sessions by phone. The comparison group receives printed educational materials. The primary outcome is body weight. Secondary outcomes include dietary fat, fruit, and vegetable intake; physical activity; stress, and affect. Mediators are self-efficacy, emotional coping response, social support, and autonomous motivation. Telephone interviews and in-person data collection at WIC offices occur at 3 time points: baseline, immediately, and 3 months after the 16-week intervention.
If MIM shows effectiveness, it could have a favorable impact on public health and community programs. The DVDs and PSGTs will be disseminated in WIC, Extension, clinical practice that promote healthy lifestyles for similar target audiences to make a broad contribution to the prevention of weight gain in low-income mothers. Also, our methodology can be adapted by researchers and community stakeholders to help other low-income populations prevent weight gain.
Trial registration
Clinical Trials Number: NCT01839708.
PMCID: PMC3987655  PMID: 24666633
Obesity prevention; Stress management; Healthy eating; Physical activity; Low-income women
14.  A Randomized Controlled Effectiveness Trial of Reciprocal Peer Support in Heart Failure 
Circulation. Heart failure  2013;6(2):246-253.
Disease management programs for patients hospitalized with heart failure (HF) although effective, are often resource intensive, limiting their uptake. Peer support programs have led to improved outcomes among patients with other chronic conditions and may result in similar improvements for HF patients.
Methods and Results
In this randomized controlled trial, Reciprocal Peer Support (RSP) arm patients participated in a HF nurse practitioner (NP)-led goal setting group session, received brief training in peer communication skills, and were paired with another participant in their cohort with whom they were encouraged to talk weekly using a telephone platform. Participants were also encouraged to attend three NP-facilitated peer support group sessions. Patients in the Nurse Care Management (NCM) arm attended a NP-led session to address their HF care questions and receive HF educational materials and information on how to access care management services. The median age of the patients was 69 years, 51% were female, and 26% were racial/ethnic minorities. Only 55% of RPS patients participated in peer calls or group sessions. In intention-to-treat analyses, the RPS and NCM groups did not differ in time to first all-cause rehospitalization or death or in mean numbers of rehospitalizations or deaths. There were no differences in improvements in 6-month measures of HF-specific quality of life or social support.
Among patients recently hospitalized for HF, over half of RPS participants had no or minimal engagement with the reciprocal peer support program, and the program did not improve outcomes compared to usual HF-nurse care management.
PMCID: PMC3782294  PMID: 23388114
heart failure; peer support; randomized controlled trial; self-management; nurse case management
15.  Smoking Characteristics and Comorbidities in the Power To Quit Randomized Clinical Trial for Homeless Smokers 
Nicotine & Tobacco Research  2012;15(1):22-28.
Smoking prevalence in homeless populations is strikingly high (∼70%); yet, little is known about effective smoking cessation interventions for this population. We conducted a community-based clinical trial, Power To Quit (PTQ), to assess the effects of motivational interviewing (MI) and nicotine patch (nicotine replacement therapy [NRT]) on smoking cessation among homeless smokers. This paper describes the smoking characteristics and comorbidities of smokers in the study.
Four hundred and thirty homeless adult smokers were randomized to either the intervention arm (NRT + MI) or the control arm (NRT + Brief Advice). Baseline assessment included demographic information, shelter status, smoking history, motivation to quit smoking, alcohol/other substance abuse, and psychiatric comorbidities.
Of the 849 individuals who completed the eligibility survey, 578 (68.1%) were eligible and 430 (74.4% of eligibles) were enrolled. Participants were predominantly Black, male, and had mean age of 44.4 years (S D = 9.9), and the majority were unemployed (90.5%). Most participants reported sleeping in emergency shelters; nearly half had been homeless for more than a year. Nearly all the participants were daily smokers who smoked an average of 20 cigarettes/day. Nearly 40% had patient health questionnaire-9 depression scores in the moderate or worse range, and more than 80% screened positive for lifetime history of drug abuse or dependence.
This study demonstrates the feasibility of enrolling a diverse sample of homeless smokers into a smoking cessation clinical trial. The uniqueness of the study sample enables investigators to examine the influence of nicotine dependence as well as psychiatric and substance abuse comorbidities on smoking cessation outcomes.
PMCID: PMC3611988  PMID: 22589422
16.  Evaluating the dissemination of Body & Soul, an evidence-based fruit and vegetable intake intervention: challenges for dissemination and implementation research 
To evaluate whether the evidence-based Body & Soul program, when disseminated and implemented without researcher or agency involvement and support, would achieve similar results to earlier efficacy and effectiveness trials.
Prospective group randomized trial.
Churches with predominantly African American membership.
A total of 1033 members from the fifteen churches completed baseline surveys. Of these, 562 (54.4%) completed the follow-up survey six months later.
Church-based nutrition program for African Americans that included pastoral involvement, educational activities, church environmental changes, and peer counseling.
Main Outcome Measure
Daily fruit and vegetable (FV) intake was assessed at pre- and post-test.
Mixed-effects linear models.
At posttest, there was no statistically significant difference in daily servings of FV between the early intervention group participants compared to control group participants (4.7 vs, 4.4, P=0.38). Process evaluation suggested that added resources such as technical assistance could improve program implementation.
Conclusions and Implications
The disseminated program may not produce improvements in FV intake equal to those in the earlier efficacy and effectiveness trials, primarily due to lack of program implementation. Program dissemination may not achieve public health impact unless support systems are strengthened for adequate implementation at the church level.
PMCID: PMC3374882  PMID: 22406012
diet; health behavior; health promotion; program evaluation; African Americans
17.  Culturally specific versus standard group cognitive behavioral therapy for smoking cessation among African Americans: an RCT protocol 
BMC psychology  2013;1(1):15.
African American smokers experience disproportionately higher rates of tobacco-related illnesses compared to Caucasians. It has been suggested that interventions targeted to specific racial/ethnic groups (i.e., culturally specific) are needed; however, the literature examining the efficacy of culturally specific interventions is equivocal. Moreover, there are few descriptions of methods used to create these interventions. The main aim of this study is to test the efficacy of a culturally specific smoking cessation intervention among African Americans.
A 2-arm randomized controlled trial (RCT) will be conducted to assess the efficacy of a culturally specific group cognitive behavioral therapy (CBT), compared to standard group CBT among treatment-seeking smokers from the community. Participants in both conditions receive the transdermal nicotine patch (TNP) for 8-weeks. We intend to randomize at least 247 adult smokers who self-identify as African American into the trial. Enrolled participants are block randomized into one of two groups: Standard group CBT (control) or a culturally specific group CBT (CS-CBT). Groups are matched for time and attention, and consist of eight sessions. The primary outcome variable is 7-day point prevalence abstinence (7-day ppa). Smoking status is assessed at the end-of-counseling (EOC), and 3, 6, and 12-month follow-ups, with self-reported abstinence verified by saliva cotinine. We hypothesize that the CS-CBT condition will produce significantly greater smoking cessation rates compared to the control condition. We also expect that this effect will be moderated by acculturation and ethnic identity, such that the CS-CBT will show the greatest effect on cessation among participants who are less acculturated and have greater ethnic identity.
Answering the fundamental question of whether culturally specific interventions lead to incremental efficacy over established, evidence-based approaches is of utmost importance. This study will have implications for the development and implementation of smoking cessation interventions among African Americans and other racial/ethnic minority groups.
Trial registration
PMCID: PMC4269979  PMID: 25566367
Smoking cessation; African Americans; Culturally specific; Cognitive behavioral therapy
18.  Design of a randomized controlled trial for multiple cancer risk behaviors among Spanish-speaking Mexican-origin smokers 
BMC Public Health  2013;13:237.
Smoking, poor diet, and physical inactivity account for as much as 60% of cancer risk. Latinos experience profound disparities in health behaviors, as well as the cancers associated with them. Currently, there is a dearth of controlled trials addressing these health behaviors among Latinos. Further, to the best of our knowledge, no studies address all three behaviors simultaneously, are culturally sensitive, and are guided by formative work with the target population. Latinos represent 14% of the U.S. population and are the fastest growing minority group in the country. Efforts to intervene on these important lifestyle factors among Latinos may accelerate the elimination of cancer-related health disparities.
The proposed study will evaluate the efficacy of an evidence-based and theoretically-driven Motivation And Problem Solving (MAPS) intervention, adapted and culturally-tailored for reducing cancer risk related to smoking, poor diet, and physical inactivity among high-risk Mexican-origin smokers who are overweight/obese (n = 400). Participants will be randomly assigned to one of two groups: Health Education (HE) or MAPS (HE + up to 18 MAPS counseling calls over 18 months). Primary outcomes are smoking status, servings of fruits and vegetables, and both self-reported and objectively measured physical activity. Outcome assessments will occur at baseline, 6 months, 12 months, and 18 months.
The current study will contribute to a very limited evidence base on multiple risk factor intervention studies on Mexican-origin individuals and has the potential to inform both future research and practice related to reducing cancer risk disparities. An effective program targeting multiple cancer risk behaviors modeled after chronic care programs has the potential to make a large public health impact because of the dearth of evidence-based interventions for Latinos and the extended period of support that is provided in such a program.
Trial registration
National Institutes of Health Clinical Trials Registry # NCT01504919
PMCID: PMC3610197  PMID: 23506397
Latinos; Mexican; Mexican American; Smoking cessation; Fruits/vegetables; Physical activity
19.  Promoting Fruit and Vegetable Consumption Among Members of Black Churches, Michigan and North Carolina, 2008–2010 
Evidence-based health promotion programs that are disseminated in community settings can improve population health. However, little is known about how effective such programs are when they are implemented in communities. We examined community implementation of an evidence-based program, Body and Soul, to promote consumption of fruits and vegetables.
We randomly assigned 19 churches to 1 of 2 arms, a colon cancer screening intervention or Body and Soul. We conducted our study from 2008 through 2010. We used the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework to evaluate the program and collected data via participant surveys, on-site observations, and interviews with church coordinators and pastors.
Members of 8 churches in Michigan and North Carolina participated in the Body and Soul program. Mean fruit and vegetable consumption increased from baseline (3.9 servings/d) to follow-up (+0.35, P = .04). The program reached 41.4% of the eligible congregation. Six of the 8 churches partially or fully completed at least 3 of the 4 program components. Six churches expressed intention to maintain the program. Church coordinators reported limited time and help to plan and implement activities, competing church events, and lack of motivation among congregation members as barriers to implementation.
The RE-AIM framework provided an effective approach to evaluating the dissemination of an evidence-based program to promote health. Stronger emphasis should be placed on providing technical assistance as a way to improve other community-based translational efforts.
PMCID: PMC3600872  PMID: 23489638
Health Psychology  2009;28(4):394-403.
Many targeted health interventions have been developed and tested with African American (AA) populations; however, AAs are a highly heterogeneous group. One characteristic that varies across AAs is Ethnic Identity (EI). Despite the recognition that AAs are heterogeneous with regard to EI, little research has been conducted on how to incorporate EI into the design of health messages and programs.
This randomized trial tested whether tailoring a print-based fruit and vegetable (F & V) intervention based on individual EI would enhance program impact beyond that of social cognitive tailoring alone. AA adults were recruited from two integrated healthcare delivery systems, one based in the Detroit Metro area and the other in the Atlanta Metro area, and then randomized to receive three newsletters focused on F & V behavior change over three months. One set of newsletters was tailored only on demographic, behavioral, and social cognitive variables (control condition) whereas the other (experimental condition) was additionally tailored on EI.
Main Outcome Measures
The primary outcome for the study was F & V intake, which was assessed at baseline and three months later using the composite of two brief self-report frequency measures.
A total of 560 eligible participants were enrolled, of which 468 provided complete 3-month follow-up data. The experimental group increased their daily mean F & V intake by 1.1 servings compared to .8 servings in the control group (p = .13). Several variables were found to interact with intervention group. For instance, Afrocentric experimental group participants showed a 1.4 increase in F & V servings per day compared to a .43 servings per day increase among Afrocentric controls (p < .05).
Although the overall between-group effects were not significant, this study confirms that AAs are a highly diverse population and that tailoring dietary messages on ethnic identity may improve intervention impact for some AA subgroups.
PMCID: PMC3397196  PMID: 19594262
21.  Motivational Interviewing for encouraging quit attempts among unmotivated smokers: study protocol of a randomized, controlled, efficacy trial 
BMC Public Health  2012;12:456.
Although the current Clinical Practice Guideline recommend Motivational Interviewing for use with smokers not ready to quit, the strength of evidence for its use is rated as not optimal. The purpose of the present study is to address key methodological limitations of previous studies by ensuring fidelity in the delivery of the Motivational Interviewing intervention, using an attention-matched control condition, and focusing on unmotivated smokers whom meta-analyses have indicated may benefit most from Motivational Interviewing. It is hypothesized that MI will be more effective at inducing quit attempts and smoking cessation at 6-month follow-up than brief advice to quit and an intensity-matched health education condition.
A sample of adult community resident smokers (N = 255) who report low motivation and readiness to quit are being randomized using a 2:2:1 treatment allocation to Motivational Interviewing, Health Education, or Brief Advice. Over 6 months, participants in Motivational Interviewing and Health Education receive 4 individual counseling sessions and participants in Brief Advice receive one brief in-person individual session at baseline. Rigorous monitoring and independent verification of fidelity will assure the counseling approaches are distinct and delivered as planned. Participants complete surveys at baseline, week 12 and 6-month follow-up to assess demographics, smoking characteristics, and smoking outcomes. Participants who decide to quit are provided with a self-help guide to quitting, help with a quit plan, and free pharmacotherapy. The primary outcome is self-report of one or more quit attempts lasting at least 24 hours between randomization and 6-month follow-up. The secondary outcome is biochemically confirmed 7-day point prevalence cessation at 6-month follow-up. Hypothesized mediators of the presumed treatment effect on quit attempts are greater perceived autonomy support and autonomous motivation. Use of pharmacotherapy is a hypothesized mediator of Motivational Interviewing’s effect on cessation.
This trial will provide the most rigorous evaluation to date of Motivational Interviewing’s efficacy for encouraging unmotivated smokers to make a quit attempt. It will also provide effect-size estimates of MI’s impact on smoking cessation to inform future clinical trials and inform the Clinical Practice Guideline.
Trial registration NCT01188018
PMCID: PMC3487752  PMID: 22713093
Smoking; Motivational Interviewing; Health education; Brief advice
22.  Toward systematic integration between self-determination theory and motivational interviewing as examples of top-down and bottom-up intervention development: autonomy or volition as a fundamental theoretical principle 
Clinical interventions can be developed through two distinct pathways. In the first, which we call top-down, a well-articulated theory drives the development of the intervention, whereas in the case of a bottom-up approach, clinical experience, more so than a dedicated theoretical perspective, drives the intervention. Using this dialectic, this paper discusses Self-Determination Theory (SDT) [1,2] and Motivational Interviewing (MI) [3] as prototypical examples of a top-down and bottom-up approaches, respectively. We sketch the different starting points, foci and developmental processes of SDT and MI, but equally note the complementary character and the potential for systematic integration between both approaches. Nevertheless, for a deeper integration to take place, we contend that MI researchers might want to embrace autonomy as a fundamental basic process underlying therapeutic change and we discuss the advantages of doing so.
PMCID: PMC3315422  PMID: 22385828
23.  Motivational Interviewing: moving from why to how with autonomy support 
Motivational Interviewing (MI), a counseling style initially used to treat addictions, increasingly has been used in health care and public health settings. This manuscript provides an overview of MI, including its theoretical origins and core clinical strategies. We also address similarities and differences with Self-Determination Theory. MI has been defined as person-centered method of guiding to elicit and strengthen personal motivation for change. Core clinical strategies include, e.g., reflective listening and eliciting change talk. MI encourages individuals to work through their ambivalence about behavior change and to explore discrepancy between their current behavior and broader life goals and values. A key challenge for MI practitioners is deciding when and how to transition from building motivation to the goal setting and planning phases of counseling. To address this, we present a new three-phase model that provides a framework for moving from WHY to HOW; from building motivation to more action oriented counseling, within a patient centered framework.
PMCID: PMC3330017  PMID: 22385702
24.  Maternal characteristics that predict a preference for mandatory adolescent HPV vaccination 
Human Vaccines  2011;7(2):225-229.
Adolescent human papillomavirus (HPV) vaccination uptake, as a means of cervical cancer prevention, remains suboptimal with significant racial disparity. A survey study of mothers already engaging in their own cancer screening, at a predominantly black urban site and a predominantly white suburban site, finds that a majority of mothers surveyed support hypothetical mandates for adolescent HPV vaccination three years after the introduction of these vaccines. Enactment of state laws may represent an efficient means to improve HPV vaccination in adolescent daughters of these mothers. Nevertheless, in a sizable minority, maternal perceptions of the HPV vaccine may hinder adherence to these vaccination laws. In these women, tailored interventions directed at these perceptions may be required.
PMCID: PMC3166478  PMID: 21325877
mandates; maternal barriers; health behavior; legislation; teachable moment
25.  Feasibility of Using Maternal Cancer Screening Visits to Identify Adolescent Girls Eligible for Human Papillomavirus Vaccination 
Journal of Women's Health  2010;19(12):2271-2275.
Breast or cervical cancer screening visits may present an opportunity to motivate mothers to have their daughters vaccinated against human papillomavirus (HPV). In preparation for a future intervention study, we sought to establish the feasibility of using these visits to identify women with at least one daughter in the appropriate age range for adolescent HPV vaccination.
We conducted a cross-sectional mailed survey of women who had received breast or cervical cancer screening within the 6–18 months before the survey. The study was conducted at two diverse institutions: one serving a mostly black (54.1%) urban inner-city population and another serving a mostly white (87.5%) suburban population.
Our overall response rate was 28% (n = 556) in the urban site and 38% (n = 381) in the suburban site. In the urban site, the proportions of mothers completing mammography or Pap smear visits with HPV vaccine-eligible daughters were 23% and 24%, respectively. In the suburban site, the proportions of mothers completing mammography or Pap smear with at least one vaccine-eligible daughter were 41% and 26%, respectively.
Women who undergo breast or cervical cancer screening in the two different demographic groups evaluated have at least one adolescent daughter at the appropriate age for HPV vaccination. An important implication of this finding in adolescent daughters of urban mothers is the potential use of maternal breast or cervical cancer screening encounters to target a potentially undervaccinated group.
PMCID: PMC2990278  PMID: 21054184

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