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1.  Women’s interest in taking tamoxifen and raloxifene for breast cancer prevention: Response to a tailored decision aid 
Although tamoxifen can prevent primary breast cancer, few women use it as a preventive measure. A second option, raloxifene, has recently been approved. The objective of the study was to determine women’s interest in tamoxifen and raloxifene after reading a decision aid describing the risks and benefits of each medication. Women with 5-year risk of breast cancer ≥1.66 from two large health maintenance organizations were randomized to receive a decision aid versus usual care. After reading an on-line decision aid that discussed the risks and benefits of tamoxifen and raloxifene, women completed measures of risk perception, decisional conflict, behavioral intentions and actual behavior related to tamoxifen and raloxifene. 3 months following the intervention, 8.1% of participants had looked for additional information about breast cancer prevention drugs and 1.8% had talked to their doctor about tamoxifen and/or raloxifene. The majority, 54.7%, had decided to not take either drug, 0.5% had started raloxifene, and none had started tamoxifen. Participants were not particularly worried about taking tamoxifen or raloxifene and did not perceive significant benefits from taking these drugs. Over 50% did not perceive a change in their risk of getting breast cancer if they took tamoxifen or raloxifene. After reading a DA about tamoxifen and raloxifene, few women were interested in taking either breast cancer prevention drug.
doi:10.1007/s10549-011-1450-1
PMCID: PMC3742062  PMID: 21442198
decision aids; patient education; tamoxifen; raloxifene; breast cancer prevention
2.  Women’s decisions regarding tamoxifen for breast cancer prevention: Responses to a tailored decision aid 
Background
Tamoxifen reduces primary breast cancer incidence, yet has serious side effects. To date, few women with increased breast cancer risk have elected to use tamoxifen for chemoprevention. The objective of the study was to determine women’s knowledge of and attitudes toward tamoxifen following exposure to a tailored decision aid (DA).
Methods
632 women with a 5-year risk of breast cancer ≥1.66% (Mean=2.56, range=1.7-17.3) were recruited from 2 healthcare organizations. Participants viewed an online DA that informed them about their 5-year risk of breast cancer and presented individually-tailored content depicting the risks/benefits of tamoxifen prophylaxis. Outcome measures included behavioral intentions (to seek additional information about tamoxifen, to talk to a physician about tamoxifen, and to take tamoxifen); knowledge; and perceived risks and benefits of tamoxifen.
Results
After viewing the DA, 29% of participants said they intended to seek more information or talk to their doctor about tamoxifen, and only 6% believed they would take tamoxifen. Knowledge was considerable, with 63% of women answering at least 5 of 6 knowledge questions correctly. Participants were concerned about the risks of tamoxifen and many believed that the benefits of tamoxifen did not outweigh the risks.
Conclusions
This study is the largest to date to test women’s preferences for taking tamoxifen and one of the largest to have tested the impact of a tailored decision aid. After viewing the DA, women demonstrated good understanding of tamoxifen’s risks and benefits, but most were not interested in taking tamoxifen for breast cancer chemoprevention.
doi:10.1007/s10549-009-0618-4
PMCID: PMC3736824  PMID: 19908143
decision aids; patient education; tamoxifen; breast cancer prevention
3.  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
4.  Development of a survey to identify vaccine-hesitant parents 
Human Vaccines  2011;7(4):419-425.
Objective
To develop a survey to accurately assess parental vaccine hesitancy.
Results
The initial survey contained 17 items in four content domains: (1) immunization behavior; (2) beliefs about vaccine safety and efficacy; (3) attitudes about vaccine mandates and exemptions; and (4) trust. Focus group data yielded an additional 10 survey items. Expert review of the survey resulted in the deletion of nine of 27 items and revisions to 11 of the remaining 18 survey items. Parent pretesting resulted in the deletion of one item, the addition of one item, the revision of four items, and formatting changes to enhance usability. The final survey contains 18 items in the original four content domains.
Methods
An iterative process was used to develop the survey. First, we reviewed previous studies and surveys on parental health beliefs regarding vaccination to develop content domains and draft initial survey items. Focus groups of parents and pediatricians generated additional themes and survey items. Six immunization experts reviewed the items in the resulting draft survey and ranked them on a 1–5 scale for significance in identifying vaccine-hesitant parents (5 indicative of a highly significant item). The lowest third of ranked items were dropped. The revised survey was pretested with 25 parents to assess face validity, usability and item understandability.
Conclusions
The Parent Attitudes about Childhood Vaccines survey was constructed using qualitative methodology to identify vaccine-hesitant parents and has content and face validity. Further psychometric testing is needed.
doi:10.4161/hv.7.4.14120
PMCID: PMC3360071  PMID: 21389777
pediatrics; vaccination; public health practice; preventive health services; questionnaires
5.  SURVEYING ADOLESCENTS ENROLLED IN A REGIONAL HEALTHCARE DELIVERY ORGANIZATION: MAIL & PHONE FOLLOW-UP--WHAT WORKS AT WHAT COST? 
PURPOSE
To describe the differential completion rates and cost of sequential methods for a survey of adolescent regional healthcare delivery organization enrollees.
METHODS
4000 randomly selected enrollees were invited to complete a mailed health survey. Techniques used to boost response included: 1) a follow-up mailing 2) varying the appearance of the survey 3) reminder calls 4) phone calls to obtain parent and child consent and administer the survey. We evaluated the outcome and costs of these methods.
RESULTS
783 (20%) enrollees completed the 1st mailed survey, and 521 completed the 2nd, increasing the overall response rate to 33%. Completion was significantly higher for respondents who received only the plain survey than those receiving only the color (p<.001). Reminder calls boosted response by 8%. Switching to phone survey administration boosted response by 20% to 61%. The cost per completed survey was $29 for the first mailing, $26 after both mailings, $42 for mailings and reminder calls, and $48 for adding phone surveys.
CONCLUSIONS
The response to mailings and reminder calls was low and the cost high, with decreasing yield at each step, though some low cost techniques helpful. Results suggest phone surveys may be most effective among similar samples of adolescents.
doi:10.3122/jabfm.2010.04.100019
PMCID: PMC3191874  PMID: 20616296
6.  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
7.  Testing Whether Decision Aids Introduce Cognitive Biases: Results of a Randomized Trial 
Patient education and counseling  2009;80(2):158-163.
Objective
Women at high risk of breast cancer face a difficult decision whether to take medications like tamoxifen to prevent a first breast cancer diagnosis. Decision aids (DAs) offer a promising method of helping them make this decision. But concern lingers that DAs might introduce cognitive biases.
Methods
We recruited 663 women at high risk of breast cancer and presented them with a DA designed to experimentally test potential methods of identifying and reducing cognitive biases that could influence this decision, by varying specific aspects of the DA across participants in a factorial design.
Results
Participants were susceptible to a cognitive bias—an order effect—such that those who learned first about the risks of tamoxifen thought more favorably of the drug than women who learned first about the benefits. This order effect was eliminated among women who received additional information about competing health risks.
Conclusion
We discovered that the order of risk/benefit information influenced women’s perceptions of tamoxifen. This bias was eliminated by providing contextual information about competing health risks.
doi:10.1016/j.pec.2009.10.021
PMCID: PMC2889196  PMID: 20004545
8.  Challenges in Researching Racially Sensitive Topics in HMOs 
doi:10.1037/a0016389
PMCID: PMC2735257  PMID: 19594260
HMO; health plans; health disparities; cultural sensitivity; ethnic identity; African American
9.  Web-Based Smoking-Cessation Program 
Background
Initial trials of web-based smoking-cessation programs have generally been promising. The active components of these programs, however, are not well understood. This study aimed to (1) identify active psychosocial and communication components of a web-based smoking-cessation intervention and (2) examine the impact of increasing the tailoring depth on smoking cessation.
Design
Randomized fractional factorial design.
Setting
Two HMOs: Group Health in Washington State and Henry Ford Health System in Michigan.
Participants
1866 smokers.
Intervention
A web-based smoking-cessation program plus nicotine patch. Five components of the intervention were randomized using a fractional factorial design: high- versus low-depth tailored success story, outcome expectation, and efficacy expectation messages; high- versus low-personalized source; and multiple versus single exposure to the intervention components.
Measurements
Primary outcome was 7 day point-prevalence abstinence at the 6-month follow-up.
Findings
Abstinence was most influenced by high-depth tailored success stories and a high-personalized message source. The cumulative assignment of the three tailoring depth factors also resulted in increasing the rates of 6-month cessation, demonstrating an effect of tailoring depth.
Conclusions
The study identified relevant components of smoking-cessation interventions that should be generalizable to other cessation interventions. The study also demonstrated the importance of higher-depth tailoring in smoking-cessation programs. Finally, the use of a novel fractional factorial design allowed efficient examination of the study aims. The rapidly changing interfaces, software, and capabilities of eHealth are likely to require such dynamic experimental approaches to intervention discovery.
doi:10.1016/j.amepre.2007.12.024
PMCID: PMC2697448  PMID: 18407003
10.  The Role of Engagement in a Tailored Web-Based Smoking Cessation Program: Randomized Controlled Trial 
Background
Web-based programs for health promotion, disease prevention, and disease management often experience high rates of attrition. There are 3 questions which are particularly relevant to this issue. First, does engagement with program content predict long-term outcomes? Second, which users are most likely to drop out or disengage from the program? Third, do particular intervention strategies enhance engagement?
Objective
To determine: (1) whether engagement (defined by the number of Web sections opened) in a Web-based smoking cessation intervention predicts 6-month abstinence, (2) whether particular sociodemographic and psychographic groups are more likely to have lower engagement, and (3) whether particular components of a Web-based smoking cessation program influence engagement.
Methods
A randomized trial of 1866 smokers was used to examine the efficacy of 5 different treatment components of a Web-based smoking cessation intervention. The components were: high- versus low-personalized message source, high- versus low-tailored outcome expectation, efficacy expectation, and success story messages. Moreover, the timing of exposure to these sections was manipulated, with participants randomized to either a single unified Web program with all sections available at once, or sequential exposure to each section over a 5-week period of time. Participants from 2 large health plans enrolled to receive the online behavioral smoking cessation program and a free course of nicotine replacement therapy (patch). The program included: an introduction section, a section focusing on outcome expectations, 2 sections focusing on efficacy expectations, and a section with a narrative success story (5 sections altogether, each with multiple screens). Most of the analyses were conducted with a stratification of the 2 exposure types. Measures included: sociodemographic and psychosocial characteristics, Web sections opened, perceived message relevance, and smoking cessation 6-months following quit date.
Results
The total number of Web sections opened was related to subsequent smoking cessation. Participants who were younger, were male, or had less formal education were more likely to disengage from the Web-based cessation program, particularly when the program sections were delivered sequentially over time. More personalized source and high-depth tailored self-efficacy components were related to a greater number of Web sections opened. A path analysis model suggested that the impact of high-depth message tailoring on engagement in the sequentially delivered Web program was mediated by perceived message relevance.
Conclusions
Results of this study suggest that one of the mechanisms underlying the impact of Web-based smoking cessation interventions is engagement with the program. The source of the message, the degree of message tailoring, and the timing of exposure appear to influence Web-based program engagement.
doi:10.2196/jmir.1002
PMCID: PMC2630833  PMID: 18984557
Internet, World Wide Web; smoking cessation; engagement
11.  Interest in an Online Smoking Cessation Program and Effective Recruitment Strategies: Results From Project Quit 
Background
The Internet is a promising venue for delivering smoking cessation treatment, either as a stand-alone program or as an adjunct to pharmacotherapy. However, there is little data to indicate what percent of smokers are interested in receiving online smoking cessation services or how best to recruit smokers to Internet-based programs.
Objective
Using a defined recruitment sample, this study aimed to identify the percentage of smokers who expressed interest in or enrolled in Project Quit, a tailored, online, cognitive-behavioral support program offered with adjunctive nicotine replacement therapy patches. In addition, we examined the effectiveness of several individual-level versus population-level recruitment strategies.
Methods
Members from two large health care organizations in the United States were invited to participate in Project Quit. Recruitment efforts included proactive invitation letters mailed to 34533 likely smokers and reactive population-level study advertisements targeted to all health plan members (> 560000 adults, including an estimated 98000 smokers across both health care organizations).
Results
An estimated 1.6% and 2.5% of adult smokers from each health care organization enrolled in Project Quit. Among likely smokers who received proactive study invitations, 7% visited the Project Quit website (n = 2260) and 4% (n = 1273) were eligible and enrolled. Response rates were similar across sites, despite using different sources to assemble the invitation mailing list. Proactive individual-level recruitment was more effective than other forms of recruitment, accounting for 69% of website visitors and 68% of enrollees.
Conclusions
Smokers were interested in receiving online smoking cessation support, even though they had access to other forms of treatment through their health insurance. Uptake rates for this program were comparable to those seen when smokers are advised to quit and are referred to other forms of smoking cessation treatment. In this sample, proactive mailings were the best method for recruiting smokers to Project Quit.
doi:10.2196/jmir.8.3.e14
PMCID: PMC2018826  PMID: 16954124
Internet; tobacco dependence; nicotine dependence; smoking cessation; recruitment activities

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