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.
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.
diet; health behavior; health promotion; program evaluation; African Americans
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.
National Institutes of Health Clinical Trials Registry # NCT01504919
Latinos; Mexican; Mexican American; Smoking cessation; Fruits/vegetables; Physical activity
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.
Youths eat fewer fruits and vegetables than recommended. Effective methods are needed to increase and maintain their fruit and vegetable consumption. Goal setting has been an effective behavior change procedure among adults, but has had limited effectiveness among youths. Implementation intentions are specific plans to facilitate goal attainment. Redefining goal setting to include implementation intentions may be an effective way to increase effectiveness. Video games offer a controlled venue for conducting behavioral research and testing hypotheses to identify mechanisms of effect.
This report describes the protocol that guided the design and evaluation of Squire’s Quest! II, a video game aimed to increase child fruit and vegetable consumption.
Squire’s Quest! II is a 10-episode videogame promoting fruit and vegetable consumption to 4th and 5th grade children (approximately 9-11 year old youths). A four group randomized design (n=400 parent/child dyads) was used to systematically test the effect of two types of implementation intentions (action, coping) on fruit and vegetable goal attainment and consumption of 4th and 5th graders. Data collection occurred at baseline, immediately post game-play, and 3 months later. Child was the unit of assignment. Three dietary recalls were collected at each data collection period by trained interviewers using the Nutrient Data System for Research (NDSR 2009). Psychosocial and process data were also collected.
To our knowledge, this is the first research to explore the effect of implementation intentions on child fruit and vegetable goal attainment and consumption.
This intervention will contribute valuable information regarding whether implementation intentions are effective with elementary age children.
video game, nutrition, fruit, vegetable, children, intervention, action implementation intention, coping implementation intention, goal setting
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.
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.
Smoking; Motivational Interviewing; Health education; Brief advice
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)  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.
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.
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.
mandates; maternal barriers; health behavior; legislation; teachable moment
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.
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.
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.
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.
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.
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.
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.
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.
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.
Assessing EI of AAs in research studies may help identify groups at risk for dropout and/or non-response.
Ethnic identity; African American; tailored health communication
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.
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.
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.
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.
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.
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.
AIDS; Medication adherence; Antiretroviral medication
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.
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.
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.
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.
psychosocial correlates; adolescents; African Americans; sex differences; motivation; self-efficacy
Computer tailoring and motivational interviewing show promise in promoting lifestyle change, despite few head-to-head comparative studies.
Vitalum is a randomized controlled trial in which the efficacy of these methods was compared in changing physical activity and fruit and vegetable consumption in middle-aged Dutch adults.
Participants (n = 1,629) were recruited via 23 general practices and randomly received either four tailored print letters, four motivational telephone calls, two of each type of intervention, or no information. The primary outcomes were absolute change in self-reported physical activity and fruit and vegetable consumption.
All three intervention groups (i.e., the tailored letters, the motivational calls, and the combined version) were equally and significantly more effective than the control group in increasing physical activity (hours/day), intake of fruit (servings/day), and consumption of vegetables (grams/day) from baseline to the intermediate measurement (week 25), follow-up 1 (week 47) and 2 (week 73). Effect sizes (Cohen’s d) ranged from 0.15 to 0.18. Participants rated the interventions positively; interviews were more positively evaluated than letters.
Tailored print communication and telephone motivational interviewing or their combination are equally successful in changing multiple behaviors.
Electronic supplementary material
The online version of this article (doi:10.1007/s12160-010-9231-3) contains supplementary material, which is available to authorized users.
Fruit and vegetable consumption; Physical activity; Motivational interviewing; Computer tailoring; Pedometer
HMO; health plans; health disparities; cultural sensitivity; ethnic identity; African American
We assessed the impact of a pilot middle school a la carte intervention on food and beverage purchases, kilocalories, fat, carbohydrate, and protein sold per student, and nutrient density of the foods sold. A la carte sales were obtained from six middle schools in three states for 1 baseline week and daily during the 6-week intervention. Intervention goals included reducing sizes of sweetened beverages and chips, and increasing the availability of water and reduced-fat/baked chips. Nutrients sold per day were computed and weekly nutrient means per student and per number of items sold were calculated and compared between baseline and week 6. Five schools achieved all goals at 6 weeks. Four schools showed increases in the percentage of kilocalories from protein and decreases in the amount of sweetened beverages sold; five showed substantial increases in water sales. Changes in regular chips varied by school. There were significant changes in energy density of foods sold. School foodservice changes in middle school snack bar/a la carte lines can be implemented and can lead to a reduction in the caloric density of foods purchased.
Our objective for this study was to examine the feasibility of instituting environmental changes during a 6-week pilot in school foodservice programs, with long-term goals of improving dietary quality and preventing obesity and type 2 diabetes in youth. Participants included students and staff from six middle schools in three states. Formative assessment with students and school staff was conducted in the spring of 2003 to inform the development of school foodservice policy changes. Thirteen potential policy goals were delineated. These formed the basis for the environmental change pilot intervention implemented during the winter/spring of 2004. Questionnaires were used to assess the extent to which the 13 foodservice goals were achieved. Success was defined as achieving 75% of goals not met at baseline. Daily data were collected on goal achievement using the schools’ daily food production and sales records. Qualitative data were also collected after the pilot study to obtain feedback from students and staff. Formative research with staff and students identified potential environmental changes. Most schools made substantial changes in the National School Lunch Program meal and snack bar/a la carte offerings. Vending goals were least likely to be achieved. Only one school did not meet the 75% goal achievement objective. Based on the objective data as well as qualitative feedback from student focus groups and interviews with students and school staff, healthful school foodservice changes in the cafeteria and snack bar can be implemented and were acceptable to the staff and students. Implementing longer-term and more ambitious changes and assessing cost issues and the potential enduring impact of these changes on student dietary change and disease risk reduction merits investigation.
A large proportion of adults fail to meet public health guidelines for physical activity as well as fruit, vegetable and fat intake. Interventions are needed to improve these health behaviors. Both computer tailoring and motivational interviewing have shown themselves to be promising techniques for health behavior change. The Vitalum project aims to compare the efficacy of these techniques in improving the health behaviors of adults aged 45–70. This paper describes the design of the Vitalum study.
Dutch general medical practices (N = 23) were recruited via a registration network or by personal invitation. The participants were then enrolled through these general practices using an invitational letter. They (n = 2,881) received a written baseline questionnaire to assess health behaviors, and potential psychosocial and socio-demographic behavioral determinants. A power analysis indicated that 1,600 participants who were failing to meet the guidelines for physical activity and either fruit or vegetable consumption were needed. Eligible participants were stratified based on hypertension status and randomized into one of four intervention groups: tailored print communication, telephone motivational interviewing, combined, and control. The first two groups either received four letters or took part in four interviews, whereas the combined group received two letters and took part in two interviews in turns at 5, 13, 30 and 43 weeks after returning the baseline questionnaire. Each letter and interview focused on physical activity or nutrition behavior. The participants also took part in a telephone survey 25 weeks after baseline to gather new information for tailoring. There were two follow-up questionnaires, at 47 and 73 weeks after baseline, to measure short- and long-term effects. The control group received a tailored letter after the last posttest. The process, efficacy and cost-effectiveness of the interventions will be examined by means of multilevel mixed regression, cost-effectiveness analyses and process evaluation.
The Vitalum study simultaneously evaluates the efficacy of tailored print communication and telephone motivational interviewing, and their combined use for multiple behaviors and people with different motivational stages and education levels. The results can be used by policymakers to contribute to evidence-based prevention of chronic diseases.
Dutch Trial Register NTR1068
The study of health behavior change, including nutrition and physical activity behaviors, has been rooted in a cognitive-rational paradigm. Change is conceptualized as a linear, deterministic process where individuals weigh pros and cons, and at the point at which the benefits outweigh the cost change occurs. Consistent with this paradigm, the associated statistical models have almost exclusively assumed a linear relationship between psychosocial predictors and behavior. Such a perspective however, fails to account for non-linear, quantum influences on human thought and action. Consider why after years of false starts and failed attempts, a person succeeds at increasing their physical activity, eating healthier or losing weight. Or, why after years of success a person relapses. This paper discusses a competing view of health behavior change that was presented at the 2006 annual ISBNPA meeting in Boston.
Rather than viewing behavior change from a linear perspective it can be viewed as a quantum event that can be understood through the lens of Chaos Theory and Complex Dynamic Systems. Key principles of Chaos Theory and Complex Dynamic Systems relevant to understanding health behavior change include: 1) Chaotic systems can be mathematically modeled but are nearly impossible to predict; 2) Chaotic systems are sensitive to initial conditions; 3) Complex Systems involve multiple component parts that interact in a nonlinear fashion; and 4) The results of Complex Systems are often greater than the sum of their parts. Accordingly, small changes in knowledge, attitude, efficacy, etc may dramatically alter motivation and behavioral outcomes. And the interaction of such variables can yield almost infinite potential patterns of motivation and behavior change. In the linear paradigm unaccounted for variance is generally relegated to the catch all "error" term, when in fact such "error" may represent the chaotic component of the process. The linear and chaotic paradigms are however, not mutually exclusive, as behavior change may include both chaotic and cognitive processes. Studies of addiction suggest that many decisions to change are quantum rather than planned events; motivation arrives as opposed to being planned. Moreover, changes made through quantum processes appear more enduring than those that involve more rational, planned processes. How such processes may apply to nutrition and physical activity behavior and related interventions merits examination.
Persuading patients to change behaviour that is damaging their health can be difficult. Changing the style of consultation could improve the experience for doctors and patients
Because African Americans tend to have lower socioeconomic status (SES) than whites and numerous health indicators are related to SES variables, it is important when examining between-group differences in health indices to account for SES differences. This studyexamined the effects of income and education on several biologic and behavioral risk factors in a sample of sociodemographicallydiverse African American adults. Approximately 1,000 African American adults (aged 18–87) were recruited from 14 churches with predominantlyblack membership to participate in a nutrition education intervention. Demographics, height, weight, blood pressure, self-reported cigarette and alcohol use, self-reported diet byfood frequencyquestionnaire, serum carotenoids, serum total cholesterol, and nutrition knowledge were assessed. The association of these risk factors were examined byfour levels of education and income. For men, bodymass index, blood pressure, total cholesterol, dailyintake of fruits and vegetables, serum carotenoids, heavyalcohol use, or exercise were not associated significantlywith income or education using analysis of variance (ANOVA). Past month alcohol use and nutrition knowledge were associated positivelywith education, but not income. For women, bodymass index and smoking were associated inverselywith income, but not with education. Blood pressure, total cholesterol, intake of fruits and vegetables, heavyalcohol use, and exercise were not associated with either income or education using ANOVA., Serum carotenoids, any 30-dayalcohol use, and nutrition knowledge were associated positivelywith both income and education. Results using linear regression generallywere similar for men and women, although a few more variables were associated significantlywith SES compared to ANOVA analyses. Several health indicators that have been associated with socioeconomic variables in whites were not associated or onlyweaklyassociated in this diverse sample of African Americans. One interpretation of these findings is that SES factors mayfunction differentlyamong blacks and whites.
Blacks; Cardiovascular Risk Factors; Ethnicity; Sociodemographics