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1.  Validation of PIN 3 physical activity survey in low-income overweight and obese young mothers 
BMC Public Health  2015;15:121.
Background
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.
Methods
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.
Results
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.
Conclusions
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
doi:10.1186/s12889-015-1493-z
PMCID: PMC4331310
Validity; Physical activity survey; Low-income women
2.  Development and psychometric properties of a brief measure of subjective decision quality for breast cancer treatment 
Background
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1186/s12911-014-0110-x
PMCID: PMC4272518  PMID: 25476986
Breast cancer; Oncology; Decision making; Decision quality; Decision satisfaction; Scale development; Psychometric testing
3.  A Diabetes Peer Support Intervention That Improved Glycemic Control: Mediators and Moderators of Intervention Effectiveness 
Chronic illness  2013;9(4):10.1177/1742395313476522.
Objective
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.
Methods
We conducted secondary analyses for 212 type 2 diabetes patients participating in the trial using accepted methods for testing effect mediation and moderation.
Results
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).
Discussion
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.
doi:10.1177/1742395313476522
PMCID: PMC3830685  PMID: 23585636
self-management; behavior change; peer-support
4.  A Randomized Trial of an Avatar-Hosted Multiple Behavior Change Intervention for Young Adult Smokers 
Background
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.
Methods
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.
Results
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).
Conclusions
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.
doi:10.1093/jncimonographs/lgt021
PMCID: PMC3881995  PMID: 24395994
5.  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.
AIMS
To assess the effects of adding motivational interviewing (MI) counseling to nicotine patch for smoking cessation among homeless smokers.
DESIGN
Two-group randomized controlled trial with 26-week follow-up.
PARTICIPANTS AND SETTING
430 homeless smokers from emergency shelters and transitional housing units in Minneapolis/St. Paul, Minnesota, USA.
INTERVENTION AND MEASUREMENTS
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.
FINDINGS
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).
CONCLUSIONS
Adding motivational interviewing counseling to nicotine patch did not significantly increase smoking rate at 26-week follow-up for homeless smokers.
doi:10.1111/add.12140
PMCID: PMC3651796  PMID: 23510102
6.  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.
doi:10.1080/10810730.2010.525296
PMCID: PMC4013828  PMID: 21154086
7.  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.
Background
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.
Methods/Design
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.
Discussion
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.
doi:10.1186/1471-2458-14-280
PMCID: PMC3987655  PMID: 24666633
Obesity prevention; Stress management; Healthy eating; Physical activity; Low-income women
8.  A Randomized Controlled Effectiveness Trial of Reciprocal Peer Support in Heart Failure 
Circulation. Heart failure  2013;6(2):246-253.
Background
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.
Conclusions
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.
doi:10.1161/CIRCHEARTFAILURE.112.000147
PMCID: PMC3782294  PMID: 23388114
heart failure; peer support; randomized controlled trial; self-management; nurse case management
9.  Smoking Characteristics and Comorbidities in the Power To Quit Randomized Clinical Trial for Homeless Smokers 
Nicotine & Tobacco Research  2012;15(1):22-28.
Introduction:
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.
Methods:
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.
Results:
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.
Conclusions:
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.
doi:10.1093/ntr/nts030
PMCID: PMC3611988  PMID: 22589422
10.  Evaluating the dissemination of Body & Soul, an evidence-based fruit and vegetable intake intervention: challenges for dissemination and implementation research 
Objective
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.
Design
Prospective group randomized trial.
Setting
Churches with predominantly African American membership.
Participants
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.
Intervention
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.
Analysis
Mixed-effects linear models.
Results
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.
doi:10.1016/j.jneb.2011.09.002
PMCID: PMC3374882  PMID: 22406012
diet; health behavior; health promotion; program evaluation; African Americans
11.  Culturally specific versus standard group cognitive behavioral therapy for smoking cessation among African Americans: an RCT protocol 
BMC psychology  2013;1(1):15.
Background
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.
Methods/Design
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.
Discussion
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
NCT01811758
doi:10.1186/2050-7283-1-15
PMCID: PMC4269979  PMID: 25566367
Smoking cessation; African Americans; Culturally specific; Cognitive behavioral therapy
12.  Design of a randomized controlled trial for multiple cancer risk behaviors among Spanish-speaking Mexican-origin smokers 
BMC Public Health  2013;13:237.
Background
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.
Methods/design
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.
Discussion
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
doi:10.1186/1471-2458-13-237
PMCID: PMC3610197  PMID: 23506397
Latinos; Mexican; Mexican American; Smoking cessation; Fruits/vegetables; Physical activity
13.  Promoting Fruit and Vegetable Consumption Among Members of Black Churches, Michigan and North Carolina, 2008–2010 
Introduction
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.5888/pcd10.120161
PMCID: PMC3600872  PMID: 23489638
14.  TAILORING A FRUIT AND VEGETABLE INTERVENTION ON ETHNIC IDENTITY: RESULTS OF A RANDOMIZED STUDY 
Health Psychology  2009;28(4):394-403.
Objective
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.
Design
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.
Results
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).
Conclusions
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.
doi:10.1037/a0015217
PMCID: PMC3397196  PMID: 19594262
15.  Motivational Interviewing for encouraging quit attempts among unmotivated smokers: study protocol of a randomized, controlled, efficacy trial 
BMC Public Health  2012;12:456.
Background
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.
Methods/Design
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.
Discussion
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
ClinicalTrials.gov NCT01188018
doi:10.1186/1471-2458-12-456
PMCID: PMC3487752  PMID: 22713093
Smoking; Motivational Interviewing; Health education; Brief advice
16.  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.
doi:10.1186/1479-5868-9-23
PMCID: PMC3315422  PMID: 22385828
17.  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.
doi:10.1186/1479-5868-9-19
PMCID: PMC3330017  PMID: 22385702
18.  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.
doi:10.4161/hv.7.2.13691
PMCID: PMC3166478  PMID: 21325877
mandates; maternal barriers; health behavior; legislation; teachable moment
19.  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.
Abstract
Purpose
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.
Methods
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.
Results
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.
Conclusions
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.
doi:10.1089/jwh.2010.1959
PMCID: PMC2990278  PMID: 21054184
20.  Pushing the envelope for cultural appropriateness: Does evidence support cultural tailoring in type 2 diabetes interventions for Mexican American adults? 
The Diabetes educator  2011;37(2):227-238.
Purpose
This study explores the potential utility of a culturally tailored diabetes management intervention approach by testing associations between acculturation and diabetes-related beliefs among Mexican American adults with type 2 diabetes.
Methods
Data from 288 Mexican American adults with type 2 diabetes were obtained via a bilingual, telephone-administered survey. Participants were drawn from a stratified, random sample designed to obtain maximum variability in acculturation. The survey assessed diabetes-related beliefs, intervention preferences, and three acculturation constructs from the Hazuda acculturation and assimilation scales: Spanish use, value for preserving Mexican culture, and interaction with Mexican Americans.
Results
Only one outcome, preference for a program for Mexican Americans, was associated with all three acculturation variables. Spanish use was positively associated with belief in susto as a cause of diabetes, preference for expert-driven health guidance, and involvement of others in taking care of diabetes. Value for preserving Mexican culture was related to a more holistic view of health, as evidenced by an increased likelihood of consulting a curandero, use of prayer, and interest in a diabetes program with religious content. Value for cultural preservation was also related to higher suspicion of free diabetes programs. Interaction with Mexican Americans was associated with a belief that insulin causes blindness.
Conclusions
Findings from this study suggest distinct relationships between acculturation constructs and diabetes-related beliefs and preferences, this arguing against use of a single acculturation construct to determine diabetes intervention design. Cultural tailoring may enhance the cultural appropriateness and ultimate effectiveness of diabetes interventions for Mexican American adults.
doi:10.1177/0145721710395329
PMCID: PMC3209710  PMID: 21343599
21.  Survey Response Styles, Acculturation, and Culture Among a Sample of Mexican American Adults 
Journal of cross-cultural psychology  2011;42(7):1219-1236.
A number of studies have investigated use of extreme (ERS) and acquiescent (ARS) response styles across cultural groups. However, due to within-group heterogeneity, it is important to also examine use of response styles, acculturation, and endorsement of cultural variables at the individual level. This study explores relationships between acculturation, six Mexican cultural factors, ERS, and ARS among a sample of 288 Mexican American telephone survey respondents. Three aspects of acculturation were assessed: Spanish use, the importance of preserving Mexican culture, and interaction with Mexican Americans versus Anglos. These variables were hypothesized to positively associate with ERS and ARS. Participants with higher Spanish use did utilize more ERS and ARS; however, value for preserving Mexican culture and interaction with Mexican Americans were not associated with response style use. In analyses of cultural factors, endorsement of familismo and simpatia were related to more frequent ERS and ARS, machismo was associated with lower ERS among men, and la mujer was related to higher ERS among women. Caballerismo was marginally associated with utilization of ERS among men. No association was found between la mujer abnegada and ERS among women. Relationships between male gender roles and ARS were nonsignificant. Relationships between female gender roles and ARS were mixed but trended in the positive direction. Overall, these findings suggest that Mexican American respondents vary in their use of response styles by acculturation and cultural factors. This usage may be specifically influenced by participants' valuing of and engagement with constructs directly associated with social behavior.
doi:10.1177/0022022110383317
PMCID: PMC3171809  PMID: 21927503
22.  Ethnic Identity Predicts Loss-to-follow-up in a Health Promotion Trial 
Contemporary clinical trials  2010;31(5):414-418.
Background
Higher rates of attrition in health research have been reported for African Americans (AAs). However, little is known about which AAs are more prone to drop out and why. One potential predictor that has not been explored is Ethnic Identity (EI). This study examined the association between EI and loss-to-follow-up among AAs enrolled in a health promotion intervention to increase fruit and vegetable intake.
Methods
Five hundred and sixty AA adults from two integrated health care delivery systems in Atlanta and Detroit were enrolled into a randomized intervention trial. At baseline, all participants were classified into six EI core groups: Afrocentric, Black American, Bicultural, Multicultural, Assimilated, and High Cultural Mistrust. We examined loss-to-follow-up rates by these EI type.
Results
Overall, 92 participants (16%) were lost to follow up. Loss-to-follow-up rates were higher among those classified as Afrocentric (24%) than those without an Afrocentric identity (13%). After adjustment for covariates, Afrocentric participants were 1.9 times (CI: 1.1 – 3.6) more likely to be lost to follow up than participants without this identity type.
Conclusions
Assessing EI of AAs in research studies may help identify groups at risk for dropout and/or non-response.
doi:10.1016/j.cct.2010.06.006
PMCID: PMC3117283  PMID: 20601162
Ethnic identity; African American; tailored health communication
23.  A New Audience Segmentation Tool for African Americans: The Black Identity Classification Scale 
Journal of health communication  2010;15(5):532-554.
Many health communications target African Americans in an attempt to remediate race-based health disparities. Such materials often assume that African Americans are culturally homogeneous; however, research indicates that African Americans are heterogeneous in their attitudes, behaviors, and beliefs. The Black Identity Classification Scale (BICS) was designed as a telephone-administered tool to segment African American audiences into 16 ethnic identity types. The BICS was pretested using focus groups, telephone pretests, and a pilot study (n=306). The final scale was then administered to 625 Black adults participating in a dietary intervention study, where it generally demonstrated good internal consistency reliability. The construct validity of the BICS was also explored by comparing participants’ responses to culturally associated survey items. The distribution of the 16 BICS identity types in the intervention study is presented, as well as select characteristics for participants with core identity components. Although additional research is warranted, these findings suggest that the BICS has good psychometric properties and may be an effective tool for identifying African American audience segments.
doi:10.1080/10810730.2010.492563
PMCID: PMC3151736  PMID: 20677057
24.  Adherence to Antiretroviral Medication Regimens: A Test of a Psychosocial Model 
AIDS and behavior  2007;13(1):10-22.
Objective
The primary aim of this study was to test a psychosocial model of medication adherence among people taking antiretroviral medications. This model was based primarily on social cognitive theory and included personal (self-efficacy, outcome expectancy, stigma, depression, and spirituality), social (social support, difficult life circumstances), and provider (patient satisfaction and decision-making) variables.
Design
The data for this analysis were obtained from the parent study, which was a randomized controlled trial (Get Busy Living) designed to evaluate an intervention to foster medication adherence. Factor analysis was used to develop the constructs for the model, and structural equation modeling was used to test the model. Only baseline data were used in this cross sectional analysis.
Methods
Participants were recruited from a HIV/AIDS clinic in Atlanta, GA. Prior to group assignment, participants were asked to complete a questionnaire that included assessment of the study variables.
Results
A total of 236 participants were included in the analysis. The mean age of the participants was 41 years; the majority were male, and most were African-American. In the final model, self-efficacy and depression demonstrated direct associations with adherence; whereas stigma, patient satisfaction, and social support were indirectly related to adherence through their association with either self-efficacy or depression.
Conclusion
These findings provide evidence to reinforce the belief that medication-taking behaviors are affected by a complex set of interactions among psychosocial variables and provide direction for adherence interventions.
doi:10.1007/s10461-007-9318-4
PMCID: PMC3104939  PMID: 17978868
AIDS; Medication adherence; Antiretroviral medication
25.  The Relationship between Psychosocial Correlates and Physical Activity in Underserved Adolescent Boys and Girls in the ACT Trial 
Background
Previous research suggests motivation, enjoyment, and self-efficacy may be important psychosocial factors for understanding physical activity (PA) in youth. While previous studies have shown mixed results, emerging evidence indicates relationships between psychosocial factors and PA may be stronger in boys than girls. This study expands on previous research by examining the effects of motivation, enjoyment and self-efficacy on PA in underserved adolescent (low income, ethnic minorities) boys and girls. Based on previous literature, it was hypothesized the effects of motivation, enjoyment and self-efficacy on moderate-to-vigorous PA (MVPA) would be stronger in boys than in girls.
Methods
Baseline cross-sectional data were obtained from a randomized, school-based trial (Active by Choice Today; ACT) in underserved 6th graders (N=771 girls, 651 boys). Intrapersonal variables for PA were assessed via self-report and confirmatory factor analyses were conducted for each predictor. MVPA was assessed with 7-day accelerometry estimates.
Results
Multivariate regression analyses stratified by sex demonstrated a significant positive main effect of self-efficacy and motivation on MVPA for girls. Boys also showed a positive trend for the effect of motivation on MVPA.
Conclusions
The results from this study suggest motivation and self-efficacy should be better integrated to facilitate the development of more effective interventions for increasing PA in underserved adolescents.
PMCID: PMC3045031  PMID: 21359129
psychosocial correlates; adolescents; African Americans; sex differences; motivation; self-efficacy

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