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1.  Self-Monitoring as a Mediator of Weight Loss in the SMART Randomized Clinical Trial 
International journal of behavioral medicine  2013;20(4):10.1007/s12529-012-9259-9.
Integral components of behavioral weight-loss treatment include self-monitoring of diet and physical activity along with feedback to participants regarding their behaviors. While providing feedback has been associated with weight loss, no studies have examined the impact of feedback frequency on weight loss, or the mediating role of self-monitoring adherence in this relationship.
This study examined the effect of participant feedback frequency on weight loss and determined if this effect was mediated by adherence to self-monitoring in a behavioral weight-loss trial conducted in the United States.
Participants (N=210) were randomly assigned to one of three self-monitoring methods with either no daily feedback messages or daily feedback messages: 1) paper diary (PD)- no daily feedback, 2) personal digital assistant (PDA)- no daily feedback, and 3) PDA- daily, tailored feedback messages (PDA+FB). The Sobel test via bootstrapping examined the direct effect of feedback frequency on weight loss and the indirect effect through self-monitoring adherence.
Receiving daily feedback messages significantly increased participants’ self-monitoring adherence. A significant effect of feedback frequency on weight loss was noted; however, after adjusting for self-monitoring adherence, the effect of feedback frequency on weight loss was no longer significant. Feedback frequency had a significant indirect effect on weight loss through self-monitoring adherence.
Self-monitoring adherence mediated the effect of feedback frequency on weight loss. Increasing the frequency with which participants receive feedback could enhance self-monitoring adherence, a critical component of behavioral weight-loss treatment.
PMCID: PMC3529986  PMID: 22936524
self-monitoring; mediation; adherence; feedback; weight loss; obesity
2.  Randomized Trial of Tailored Skin Cancer Prevention for Children: The Project SCAPE Family Study 
Journal of health communication  2013;18(11):10.1080/10810730.2013.778361.
This study evaluated a tailored intervention to promote sun protection in parents and their children, hypothesizing that the tailored intervention would lead to improved skin cancer prevention behaviors compared to generic materials. Families were recruited through schools and community centers and were included if there was one child in Grades 1–3 at moderate to high risk for skin cancer. Participants were randomized into one of two intervention groups: a tailored intervention, in which they received personalized skin cancer education through the mail; or a control group who received generic skin cancer information materials. Both pre- and post-intervention, parents completed questionnaires about their and their children’s skin cancer risk and prevention knowledge and behaviors. Parents also completed 4-day sun exposure and protection diaries for their child and themselves. Tailored group participants demonstrated significantly greater positive changes in prevention behavior after the intervention, including children’s use of sunscreen, shirts, and hats, and parents’ use of shade, and skin examinations. Effect sizes were small and perceived benefits and social norms mediated intervention effects. Findings from this study support the efficacy of focusing tailored communications to families in order to change skin cancer prevention practices in young children.
PMCID: PMC3815976  PMID: 23806094
3.  Psychosocial Assessments for HIV+ African Adolescents: Establishing Construct Validity and Exploring Under-Appreciated Correlates of Adherence 
PLoS ONE  2014;9(10):e109302.
Study Objectives
Psychosocial factors such as outcome expectancy, perceived stigma, socio-emotional support, consideration of future consequences, and psychological reactance likely influence adolescent adherence to antiretroviral treatments. Culturally-adapted and validated tools for measuring these factors in African adolescents are lacking. We aimed to identify culturally-specific factors of importance to establishing local construct validity in Botswana.
Using in-depth interviews of 34 HIV+ adolescents, we explored how the psychosocial factors listed above are perceived in this cultural context. We evaluated six scales that have been validated in other contexts. We also probed for additional factors that the adolescents considered important to their HIV medication adherence. Analyses were conducted with an analytic framework approach using NVivo9 software.
While the construct validity of some Western-derived assessment tools was confirmed, other tools were poorly representative of their constructs in this cultural context. Tools chosen to evaluate HIV-related outcome expectancy and perceived stigma were well-understood and relevant to the adolescents. Feedback from the adolescents suggested that tools to measure all other constructs need major modifications to obtain construct validity in Botswana. The scale regarding future consequences was poorly understood and contained several items that lacked relevance for the Batswana adolescents. They thought psychological reactance played an important role in adherence, but did not relate well to many components of the reactance scale. Measurement of socio-emotional support needs to focus on the adolescent-parent relationship, rather than peer-support in this cultural context. Denial of being HIV-infected was an unexpectedly common theme. Ambivalence about taking medicines was also expressed.
In-depth interviews of Batswana adolescents confirmed the construct validity of some Western-developed psychosocial assessment tools, but demonstrated limitations in others. Previously underappreciated factors related to HIV medication adherence, such as denial and ambivalence, should be further explored.
PMCID: PMC4184864  PMID: 25279938
4.  Pre-consent education about research processes improved African Americans’ willingness to participate in clinical research 
Journal of clinical epidemiology  2011;64(8):872-877.
To determine whether pre-consent education about research processes and protections affects African-Americans’ willingness to participate.
This study examined the willingness of 192 African-American outpatients (stratified by age, gender, and education) to participate in a hypothetical clinical study under varying consent conditions: Phase I participants underwent a typical informed consent process and were asked to indicate whether they would be willing to participate in the hypothetical clinical study and the reasons for their decision; their responses were used to develop a pre-consent educational DVD. Phase II participants viewed the DVD prior to the consent process. We compared the proportion of those who stated they were willing to participate in the clinical study using Fisher’s exact tests, and used qualitative methods to analyze open-ended responses.
When the consent process included education about research processes and protections, significantly more patients reported willingness to participate in the hypothetical clinical study (43% vs. 27%; p=0.002). Patients receiving pre-consent education were significantly less likely to cite mistrust, fear of side effects, lack of perceived benefits, and privacy as reasons for not participating.
Pre-consent education may improve the willingness of African-Americans to participate in clinical research and may address important concerns about research participation.
PMCID: PMC4108901  PMID: 21330104
clinical trial; consent; HIPAA; minority groups; patient participation
5.  The impact of HIPAA authorization on willingness to participate in clinical research 
Annals of epidemiology  2007;17(11):899-905.
This study systematically examines the impact of inclusion of HIPAA authorization on the willingness of African Americans of diverse sociodemographic characteristics to participate in a clinical research study and explores reasons for non-participation.
For a purposive sample of 384 African American outpatients at 4 metropolitan primary care clinics from August 2005 through May 2006, willingness to participate in a hypothetical clinical research study of an antihypertensive medication under one of two experimental conditions was compared. Interviewees were randomly assigned to undergo informed consent alone (control group) or informed consent with HIPAA authorization (HIPAA group). They were asked whether they would participate and reasons for their decision.
A smaller proportion of interviewees in the HIPAA group were willing to enroll in the study (27% vs. 39%; p=.02), with an adjusted odds ratio = 0.56 (95% confidence interval: 0.36 – 0.91). Those in the HIPAA group were more likely to give reasons related to privacy (p<.001), poor understanding of the form (p=.01), and mistrust or fear of research (p=0.04) for non-participation.
The inclusion of HIPAA authorization within the informed consent process may adversely affect the willingness of African Americans to participate in clinical research and may raise concerns about privacy, understanding the forms, and mistrust or fear of research.
PMCID: PMC4096152  PMID: 17689261
clinical trial; consent form; HIPAA; minority groups; patient participation
6.  Children's Objective Physical Activity by Location: Why the Neighborhood Matters 
Pediatric exercise science  2013;25(3):468-486.
Knowledge of where children are active may lead to more informed policies about how and where to intervene and improve physical activity. This study examined where children aged 6–11 were physically active using time-stamped accelerometer data and parent-reported place logs and assessed the association of physical-activity location variation with demographic factors. Children spent most time and did most physical activity at home and school. Although neighborhood time was limited, this time was more proportionally active than time in other locations (e.g., active 42.1% of time in neighborhood vs. 18.1% of time at home). Children with any neighborhood-based physical activity had higher average total physical activity. Policies and environments that encourage children to spend time outdoors in their neighborhoods could result in higher overall physical activity.
PMCID: PMC4074079  PMID: 23877357
Cancer causes & control : CCC  2013;24(4):695-704.
Recognition of the complex, multidimensional relationship between excess adiposity and cancer control outcomes has motivated the scientific community to seek new research models and paradigms.
The National Cancer Institute developed an innovative concept to establish a centers grant mechanism in nutrition, energetics, and physical activity; referred to as the Transdisciplinary Research on Energetics and Cancer (TREC) Initiative. This paper gives an overview of the 2011-2016 TREC Collaborative Network and the 15 research projects being conducted at the Centers.
Four academic institutions were awarded TREC center grants in 2011: Harvard University, University of California San Diego, University of Pennsylvania, and Washington University in St. Louis. The Fred Hutchinson Cancer Research Center is the Coordination Center. The TREC research portfolio includes 3 animal studies, 3 cohort studies, 4 randomized clinical trials, 1 cross-sectional study, and 2 modeling studies. Disciplines represented by TREC investigators include basic science, endocrinology, epidemiology, biostatistics, behavior, medicine, nutrition, physical activity, genetics, engineering, health economics, and computer science. Approximately 41,000 participants will be involved in these studies, including children, healthy adults, and breast and prostate cancer survivors. Outcomes include biomarkers of cancer risk, changes in weight and physical activity, persistent adverse treatment effects (e.g., lymphedema, urinary and sexual function), and breast and prostate cancer mortality.
The NIH Science of Team Science group will evaluate the value-added by this collaborative science. However, the most important outcome will be whether this transdisciplinary initiative improves the health of Americans at risk for cancer as well as cancer survivors.
PMCID: PMC3602225  PMID: 23378138
energetics; obesity; diet; physical activity; cancer; transdisciplinary
8.  Melanoma Genetic Testing, Counseling, and Adherence to Skin Cancer Prevention and Detection Behaviors 
Little is known about the impact of knowledge of CDKN2A and MC1R genotype on melanoma prevention behaviors like sun avoidance and skin examination in the context of familial melanoma.
73 adults with a family history of melanoma were randomly assigned to be offered individualized CDKN2A and MC1R genotyping results in the context of a genetic counseling session, or the standard practice of not being offered counseling or disclosure of genotyping results. Mixed effects or longitudinal logistic models were used to determine whether the intervention affected change in sun protection habits, skin examinations and perception and beliefs related to melanoma risk, prevention, and genetic counseling.
All participants in the intervention group who attended genetic counseling sessions chose to receive their test results. From baseline to follow-up, participants in the intervention group reported an increase in the frequency of skin self-examinations compared to a slight decrease in the control group (p=0.002). Participants in the intervention group reported a smaller decrease in frequency of wearing a shirt with long sleeves than did participants in the control group (p =0.047). No effect of the intervention was noted for other outcomes.
Feedback of CDKN2A and MC1R genotype among families without known pathogenic CDKN2A mutations does not appear to decrease sun protection behaviors.
While disclosure of CDKN2A and MC1R genotype did not have negative effects on prevention, the benefits of communicating this information remain unclear. The small number of families who tested positive for CDKN2A mutations in this study is a limitation.
PMCID: PMC3617083  PMID: 23392000
skin cancer; genetic testing; sun exposure; sun protection; surveys
9.  Attitudes and barriers towards participation in an acupuncture trial among breast cancer patients: a survey study 
As breast cancer patients increasingly use complementary and alternative medicine (CAM), clinical trials are needed to guide appropriate clinical use. We sought to identify socio-demographic, clinical and psychological factors related to willingness to participate (WTP) and to determine barriers to participation in an acupuncture clinical trial among breast cancer patients.
We conducted a cross-sectional survey study among post-menopausal women with stage I-III breast cancer on aromatase inhibitors at an urban academic cancer center.
Of the 300 participants (92% response rate), 148 (49.8%) reported WTP in an acupuncture clinical trial. Higher education (p = 0.001), increased acupuncture expectancy (p < 0.001), and previous radiation therapy (p = 0.004) were significantly associated with WTP. Travel difficulty (p = 0.002), concern with experimentation (p = 0.013), and lack of interest in acupuncture (p < 0.001) were significant barriers to WTP. Barriers differed significantly by socio-demographic factors with white people more likely to endorse travel difficulty (p = 0.018) and non-white people more likely to report concern with experimentation (p = 0.024). Older patients and those with lower education were more likely to report concern with experimentation and lack of interest in acupuncture (p < 0.05).
Although nearly half of the respondents reported WTP, significant barriers to participation exist and differ among subgroups. Research addressing these barriers is needed to ensure effective accrual and improve the representation of individuals from diverse backgrounds.
PMCID: PMC3893614  PMID: 24400734
Acupuncture; Breast neoplasm; Clinical trial; Aromatase inhibitors/*adverse effects; Musculoskeletal; Joint pain; Attitudes; Barriers
10.  Objective and Self-Reported Factors Associated With Food-Environment Perceptions and Fruit-And-Vegetable Consumption: A Multilevel Analysis 
Few studies have assessed how people’s perceptions of their neighborhood environment compare with objective measures or how self-reported and objective neighborhood measures relate to consumption of fruits and vegetables.
A telephone survey of 4,399 residents of Philadelphia, Pennsylvania, provided data on individuals, their households, their neighborhoods (self-defined), their food-environment perceptions, and their fruit-and-vegetable consumption. Other data on neighborhoods (census tracts) or “extended neighborhoods” (census tracts plus 1-quarter–mile buffers) came from the US Census Bureau, the Philadelphia Police Department, the Southeastern Pennsylvania Transportation Authority, and the federal Supplemental Nutrition Assistance Program. Mixed-effects multilevel logistic regression models examined associations between food-environment perceptions, fruit-and-vegetable consumption, and individual, household, and neighborhood characteristics.
Perceptions of neighborhood food environments (supermarket accessibility, produce availability, and grocery quality) were strongly associated with each other but not consistently or significantly associated with objective neighborhood measures or self-reported fruit-and-vegetable consumption. We found racial and educational disparities in fruit-and-vegetable consumption, even after adjusting for food-environment perceptions and individual, household, and neighborhood characteristics. Having a supermarket in the extended neighborhood was associated with better perceived supermarket access (adjusted odds ratio for having a conventional supermarket, 2.04 [95% CI, 1.68–2.46]; adjusted odds ratio for having a limited-assortment supermarket, 1.28 [95% CI, 1.02–1.59]) but not increased fruit-and-vegetable consumption. Models showed some counterintuitive associations with neighborhood crime and public transportation.
We found limited association between objective and self-reported neighborhood measures. Sociodemographic differences in individual fruit-and-vegetable consumption were evident regardless of neighborhood environment. Adding supermarkets to urban neighborhoods might improve residents’ perceptions of supermarket accessibility but might not increase their fruit-and-vegetable consumption.
PMCID: PMC3970773  PMID: 24674635
11.  Nutrition-Labeling Regulation Impacts on Restaurant Environments 
Recent attempts to improve the healthfulness of away-from-home eating include regulations requiring restaurants to post nutrition information. The impact of such regulations on restaurant environments is unknown.
To examine changes in restaurant environments from before to after nutrition-labeling regulation in a newly regulated county versus a nonregulated county.
Using the Nutrition Environment Measures Surveys–Restaurant version audit, environments within the same quick-service chain restaurants were evaluated in King County (regulated) before and 6 and 18 months after regulation enforcement and in Multnomah County (nonregulated) restaurants over a 6-month period. Data were collected in 2008–2010 and analyses conducted in 2011.
Overall availability of healthy options and facilitation of healthy eating did not differentially increase in King County versus Multnomah County restaurants aside from the substantial increase in onsite nutrition information posting in King County restaurants required by the new regulation. Barriers to healthful eating decreased in King County relative to Multnomah County restaurants, particularly in food-oriented establishments. King County restaurants demonstrated modest increases in signage that promotes healthy eating, although the frequency of such promotion remained low, and the availability of reduced portions decreased in these restaurants. The healthfulness of children’s menus improved modestly over time, but not differentially by county.
A restaurant nutrition-labeling regulation was accompanied by some, but not uniform, improvements in other aspects of restaurant environments in the regulated compared to the nonregulated county. Additional opportunities exist for improving the healthfulness of awayfrom- home eating beyond menu labeling.
PMCID: PMC3479434  PMID: 23079173
12.  Impact of a Health Communication Intervention to Improve Glaucoma Treatment Adherence: Results of the I-SIGHT Trial 
Archives of ophthalmology  2012;130(10):1252-1258.
To determine the efficacy of an automated, interactive, telephone-based health communication intervention for improving glaucoma treatment adherence among patients in two hospital-based eye clinics.
Randomized controlled trial.
Two eye clinics located in hospitals in the Southeastern United States.
312 glaucoma patients aged 18 to 80 years, non-adherent with medication taking, medication refills, and/or appointment keeping
The treatment group received an automated, interactive, tailored telephone intervention and tailored printed materials. The control group received usual care.
Main Outcome Measures
Adherence with medication taking, prescription refills, and appointment keeping measured by interviews, medical charts, appointment records, and pharmacy data.
A statistically significant increase was found for all adherence measures in both the intervention and control groups. Interactive phone calls and tailored print materials did not significantly improve adherence measures compared to controls.
During the study period, patient adherence to glaucoma treatment and appointment keeping improved in both study arms. Participation in the study and interviews may have contributed. Strategies that address individuals’ barriers and facilitators may increase the impact of telephone calls, especially for appointment keeping and prescription refills.
PMCID: PMC3593648  PMID: 22688429
13.  Association Between Longer Therapy With Thiazolidinediones and Risk of Bladder Cancer: A Cohort Study 
The use of pioglitazone, a thiazolidinedione (TZD), may increase the risk of bladder cancer in patients with type 2 diabetes. In this study, we assessed the risk of bladder cancer associated with the use of TZDs and between pioglitazone and rosiglitazone, an alternative TZD.
We conducted a retrospective cohort study of patients with type 2 diabetes mellitus who initiated treatment with a TZD (n = 18 459 patients) or a sulfonylurea (SU) (n = 41 396 patients) between July 1, 2000, and August 31, 2010, using The Health Improvement Network database in the United Kingdom. Incident cancers were identified for 196 708 person-years of follow-up. Cox proportional hazards regression models were used to estimate hazard ratios (HRs) and 95% confidence intervals (CIs) for risk of bladder cancer in the TZD cohort compared with the SU cohort (referent), adjusted for potential confounders. Risk associated with increasing duration of drug exposure was also examined. All statistical tests were two-sided.
We identified 60 incident bladder cancers in the TZD cohort and 137 cancers in the SU cohort. No difference in bladder cancer risk was found between the two cohorts (TZD vs SU, HR = 0.93, 95% CI = 0.68 to 1.29) in analyses that did not account for duration of exposure. However, the risk of bladder cancer was increased among patients with the longest duration of TZD vs SU therapy (≥5 years of use, HR = 3.25, 95% CI = 1.08 to 9.71) and among those with the longest time since initiation of therapy (≥5 years since first use, HR = 2.53, 95% CI = 1.12 to 5.77). Risk of bladder cancer also increased with increasing time since initiation of pioglitazone (P trend < .001) and rosiglitazone (P trend = .006). Comparison of pioglitazone to rosiglitazone use did not demonstrate difference in cancer risk (P = .49).
Long-term TZD therapy (≥5 years) in patients with type 2 diabetes may be associated with an increased risk of bladder cancer, which may be common to all TZDs.
PMCID: PMC3529598  PMID: 22878886
14.  Changes in sunburn and tanning attitudes among lifeguards over a summer season 
Skin cancer is one of the most common cancers in the United States. Lifeguards are at increased risk of excessive sun exposure and sunburn.
We sought to examine changes in: (1) sunburn frequency over a summer while controlling for sun exposure, sun protection habits, and participation in a skin cancer prevention program; and (2) tanning attitudes while controlling for participation in the program.
Participants in this study were lifeguards (n = 3014) at swimming pools participating in the Pool Cool program in 2005. Lifeguards completed surveys at the beginning and end of the summer. Sequential regression analyses were used to assess changes in sunburn frequency and tanning attitudes.
Sunburn frequency decreased between baseline and follow-up. Having a sunburn over the summer was significantly predicted by baseline sunburn history, ethnicity, skin cancer risk, and sun exposure. The tanning attitude, “People are more attractive if they have a tan,” was significantly predicted from baseline tanning attitude and ethnicity. The second tanning attitude, “It helps to have a good base suntan,” was significantly predicted by baseline tanning attitude, ethnicity, basic/enhanced group, and moderate skin cancer risk.
Self-reported data and limited generalizability to lifeguards at other outdoor pools are limitations.
The findings showed that previous sunburn history is an important predictor of sunburn prospectively. In addition, a more risky tanning attitude is an important predictor of future attitudes toward tanning. Active involvement in targeted prevention programs may help to increase preventive behavior and health risk reduction.
PMCID: PMC3728666  PMID: 21745696
prevention; skin cancer; sun exposure; sun protection habits; sunburn; tanning attitudes
15.  Measured Occupational Solar UVR Exposures of Lifeguards in Pool Settings 
The aim of this study was to measure ultraviolet radiation (UVR) exposures of lifeguards in pool settings and evaluate their personal UVR protective practices.
Lifeguards (n = 168) wore UVR sensitive polysulfone (PS) film badges in wrist bracelets on 2 days and completed a survey and diary covering sun protection use. Analyses were used to describe sun exposure and sun protection practices, to compare UVR exposure across locations, and to compare findings with recommended threshold limits for occupational exposure.
The measured UVR exposures varied with location, ranging from high median UVR exposures of 6.2 standard erythemal doses (SEDs) to the lowest median of 1.7 SEDs. More than 74% of the lifeguards’ PS badges showed UVR above recommended threshold limits for occupational exposure. Thirty-nine percent received more than four times the limit and 65% of cases were sufficient to induce sunburn. The most common protective behaviors were wearing sunglasses and using sunscreen, but sun protection was often inadequate.
At-risk individuals were exposed to high levels of UVR in excess of occupational limits and though appropriate types of sun protection were used, it was not used consistently and more than 50% of lifeguards reported being sunburnt at least twice during the previous year.
PMCID: PMC3728671  PMID: 19572325
lifeguards; occupational UVR exposure; sun protection behaviors
16.  A Controlled Trial of Objective Measures of Sunscreen and Moisturizing Lotion 
Taking an alcohol swab of a person’s forearm and analyzing it using a spectrophotometer has been shown to be a reliable method for detecting the presence of sunscreen. The aims of this study were to determine if moisturizing lotions or other non-sun-screen products influence the absorbance readings from skin swabs in a controlled setting, and to establish the cutoff point in determining the presence or absence of sunscreen using a crystal cuvette instead of a plastic one. In a controlled trial of 30 volunteer office workers, absorbance readings from two popular brands of sunscreen with sun-protection factors (SPF) of 30 and 45 were compared with absorbance readings from two different moisturizing lotions, one with an SPF of 15 and another with no stated SPF. Moisturizers with SPF 15 tested positive for sunscreen, with absorbance readings (mean, 3.77; min, 3.30) comparable to sunblock with SPF 30 or 45 (mean, 3.51; min, 2.02). Moisturizers with no stated SPF factor tested negative for the presence of sunscreen, with extremely low absorbance readings (mean, 0.06; max, 0.19) similar to control readings. The skin swabbing technique remains a valid and useful method for detecting the presence of sunscreen and does not result in false positives when moisturizers with no stated SPF are present. Using a conservative cutoff point of 0.30 with a crystal cuvette reduces any chance of false-positive readings and remains robust when sunscreen of SPF 15 or higher is present.
PMCID: PMC3725572  PMID: 19423519
17.  Linking Agents’ Activities and Communication Patterns in a Study of the Dissemination of an Effective Skin Cancer Prevention Program 
Linking agents connect program developers with end users, enhancing implementation and sustainability of health promotion programs. However, little is known about how linkage systems work in practice and research settings.
This article describes the activities and communication patterns of field coordinators in a 4-year, national study of the dissemination of an effective skin cancer prevention program.
Descriptive and content analyses were completed for all e-mails between field coordinators and program staff and for field coordinator activity logs.
A total of 5 215 e-mails were sent to or from 62 field coordinators from 2003 to 2006. E-mails most often concerned program administration, data collection, and management of program materials. The most common activities recorded in activity logs were communication with program staff and study sites, management of surveys, and delivery and management of program materials.
Field coordinators carried out activities related to program administration and data collection across a large number of study sites. The high volume of e-mails and their emphasis on program administration issues demonstrate the importance of communication between program staff and field coordinators. It is recommended that public health researchers and practitioners implement similar linkage systems when taking effective programs to scale.
PMCID: PMC3725579  PMID: 19704309
diffusion of innovation; public health; qualitative research
18.  A Pilot Study of the Validity of Self-reported Ultraviolet Radiation Exposure and Sun Protection Practices Among Lifeguards, Parents and Children 
Photochemistry and photobiology  2008;84(3):774-778.
Outdoor recreation settings, such as swimming pools, provide a promising venue to assess UVR exposure and sun protection practices among individuals who are minimally clothed and exposed to potentially high levels of UVR. Most studies assessing sun exposure/protection practices rely on self-reported data, which are subject to bias. The aim of this study was to establish the feasibility of conducting a multimethod study to examine the validity of self-reported measures within a swimming pool setting. Data were collected from 27 lifeguards, children and parents in Hawaii. Each participant filled out a survey and a 4 day sun habits diary. On two occasions, researchers assessed observable sun protection behaviors (wearing hats, shirts, sunglasses), swabbed the skin to detect the presence of sunscreen, and subjects wore polysulphone dosimeters to measure UVR exposure. Overall, observed sun protection behaviors were more highly correlated with diary reports than with survey reports. While lifeguards and children reported spending comparable amounts of time in the sun, dosimeter measures showed that lifeguards received twice as much UVR exposure. This study demonstrated the feasibility of implementing a multimethod validity study within a broader population of swimming pools.
PMCID: PMC3725580  PMID: 18179624
19.  Tobacco Use among Native Hawaiian Middle School Students: Its Prevalence, Correlates and Implications 
Ethnicity & health  2007;12(3):227-244.
This study sought to explore whether Native Hawaiian primary ethnic identity is associated with cigarette use among Native Hawaiian middle school students. This study also explored whether social influence, psychosocial and cultural factors are associated with cigarette use in this sample.
The data are from a cross-sectional survey of 1,695 Native Hawaiian middle school students at 22 public and private schools on five islands in Hawaii. A subset of these students from Native Hawaiian serving schools (N = 136) completed additional measures of Hawaiian cultural variables.
Based on univariate analyses, students whose primary ethnic identification was Hawaiian were more likely to have tried smoking (p<0.001) and to be current smokers (p<0.05) as compared to those classified as part Hawaiian. However, these findings were no longer significant in multivariate analyses. Social influence variables (i.e. peer and parental smoking) were most influential in explaining both prior and current smoking. Attendance at public school was also an important factor in explaining previous (OR = 2.43; 95% CI = 1.74, 3.38) and current (OR = 7.20; 95% CI = 4.58, 11.32) smoking behavior. Finally, cultural variables such as valuing Hawaiian folklore, customs, activities and lifestyle were largely unassociated with smoking behavior among Native Hawaiian middle school youth.
Additional research is needed to understand what aspects of ethnic identity are associated with smoking behavior among Native Hawaiian youth. The strong influence of peer and parental smoking suggests the need for interventions that support the creation of social environments that discourage tobacco use.
PMCID: PMC3724355  PMID: 17454098
Tobacco; Adolescents; Native Hawaiian; Smoking
20.  Characteristics of swimming pools with high rates of objectively measured sunscreen use 
A combination of verbal reports, observations, and physical assessments can improve understanding of prevention programs.
Skin swabbing techniques were used to detect the presence of sunscreen as part of a sun protection measurement study at 16 swimming pools. Three pools demonstrated much higher sunscreen use (>95%) than the others (47.1%). This paper compares these three pools to the other 13 to examine whether they have common features and if different sources of data can help interpret the findings.
Data were collected from skin swabs detecting the presence of sunscreen; observations of participants; observations of pool environments; and surveys.
Pool observations showed a higher use of shade structures, sun safety signs, and other supporting items at the three high–sunscreen use pools. These three pools had significantly more year-round and long-term employees than did the other 13 pools.
Sunscreen characteristics could not be determined using the swabbing technique. Publicity about the study, or the weather, may have influenced behaviors at the pools.
Supportive environments were associated with consistent high levels of sunscreen use. This study also confirms the importance of using multiple data sources to interpret findings.
PMCID: PMC3724408  PMID: 19293015
21.  Developer and Realtor Perspectives on Factors That Influence Development, Sale, and Perceived Demand for Activity-Friendly Communities 
Although public support for physical activity-friendly Traditional Neighborhood Developments (TNDs) appears to be growing, information is lacking on private sector perspectives and how economic factors (eg, fuel prices) might influence the development and sale of TNDs.
A sample of realtors from the National Association of Realtors (n = 4950) and developers from the National Association of Home Builders (n = 162) were surveyed in early 2009 to assess factors influencing homebuyers’ decisions; incentives and barriers to developing TNDs; effects of depressed housing market conditions and financing on sales; trends in buying; and energy considerations (eg, green building).
Realtors believed that homebuyers continue to rank affordability, safety and school quality higher than TND amenities. Developers reported numerous barriers to TNDs, including the inability to overcome governmental/political hurdles, lack of cooperation between government agencies, and lack of market demand. Yet, realtors believed clients are increasingly influenced by gas and oil prices, and developers reported that clients are looking for energy efficient homes, reduced commute time, and walkable neighborhoods. Respondents reported consumers are more interested in living in a TND than 5 years ago.
Activity-friendly TNDs appear to be increasing in demand, but developers and realtors reported significant barriers to creating these communities.
PMCID: PMC3718394  PMID: 20440012
physical activity; built environment; survey research; health; motivation; public health
22.  Factors Influencing Teachers’ Implementation of an Innovative Tobacco Prevention Curriculum for Multiethnic Youth: Project SPLASH 
The Journal of school health  2008;78(5):264-273.
The effectiveness of school-based tobacco use prevention programs depends on proper implementation. This study examined factors associated with teachers’ implementation of a smoking prevention curriculum in a cluster randomized trial called Project SPLASH (Smoking Prevention Launch Among Students in Hawaii).
A process evaluation was conducted and a cross-condition comparison used to examine whether teacher characteristics, teacher training, external facilitators and barriers, teacher attitudes, and curriculum attributes were associated with the dose of teacher implementation in the intervention and control arms of the study. Data were collected from a total of 62 middle school teachers in 20 public schools in Hawaii, during the 2000-2001 and 2001-2002 school years. Sources included teacher questionnaires and interviews. Chi-square test and t test revealed that implementation dose was related to teachers’ disciplinary backgrounds and skills and student enjoyment of the curriculum.
Content analysis, within case, and cross-case analyses of qualitative data revealed that implementing the curriculum in a yearlong class schedule and high teacher self-efficacy supported implementation, while high perceived curriculum complexity was associated with less complete implementation.
The results have implications for research, school health promotion practice, and the implementation of evidence-based youth tobacco use prevention curricula.
PMCID: PMC3715092  PMID: 18387026
smoking and tobacco; school health instruction; teaching techniques
23.  Validity of covering-up sun-protection habits: Association of observations and self-report 
Few studies have reported the accuracy of measures used to assess sun-protection practices. Valid measures are critical to the internal validity and use of skin cancer control research.
We sought to validate self-reported covering-up practices of pool-goers.
A total of 162 lifeguards and 201 parent/child pairs from 16 pools in 4 metropolitan regions in the United States completed a survey and a 4-day sun-habits diary. Observations of sun-protective behaviors were conducted on two occasions.
Agreement between observations and diaries ranged from slight to substantial, with most values in the fair to moderate range. Highest agreement was observed for parent hat use (κ = 0.58–0.70). There was no systematic pattern of over- or under-reporting among the 3 study groups.
Potential reactivity and a relatively affluent sample are limitations.
There was little over-reporting and no systematic bias, which increases confidence in reliance on verbal reports of these behaviors in surveys and intervention research.
PMCID: PMC3715114  PMID: 19278750
concurrent validity; measurement; observation; self-report assessment; sun protection
24.  Using mHealth Technology to Enhance Self-Monitoring for Weight Loss A Randomized Trial 
Self-monitoring for weight loss has traditionally been performed with paper diaries. Technologic advances could reduce the burden of self-monitoring and provide feedback to enhance adherence.
To determine if self-monitoring diet using a PDA only or the PDA with daily tailored feedback (PDA+FB), was superior to using a paper diary on weight loss and maintenance.
The Self-Monitoring and Recording Using Technology (SMART) Trial was a 24-month RCCT; participants were randomly assigned to one of three self-monitoring groups.
From 2006 to 2008, 210 overweight/obese adults (84.8% female, 78.1% white) were recruited from the community. Data were analyzed in 2011.
Participants received standard behavioral treatment for weight loss which included dietary and physical activity goals, encouraged the use of self-monitoring, and was delivered in group sessions.
Main outcome measures
Percentage weight change at 24 months, adherence to self-monitoring over time.
Study retention was 85.6%. The mean percentage weight loss at 24 months was not different among groups (paper diary: −1.94% [95% CI= −3.88, 0.01], PDA: −1.38% [95% CI= – 3.38, 0.62], PDA+FB: –2.32% [95% CI= –4.29, −0.35]); only the PDA+FB group (p=0.02) demonstrated a significant loss. For adherence to self-monitoring, there was a time-by-treatment group interaction between the combined PDA groups and the paper diary group (p=0.03) but no difference between PDA and PDA+FB groups (p=0.49). Across all groups, weight loss was greater for those who were adherent ≥60% versus <30% of the time, p<0.001.
PDA+FB use resulted in a small weight loss at 24 months; PDA use resulted in greater adherence to dietary self-monitoring over time. However, for sustained weight loss, adherence to self-monitoring is more important than the method used to self-monitor. A daily feedback message delivered remotely enhanced adherence and improved weight loss, which suggests that technology can play a role in improving weight loss.
PMCID: PMC3563396  PMID: 22704741
25.  Cancer Outcomes Research in a Rural Area: A Multi-Institution Partnership Model 
Journal of community health  2009;34(1):23-32.
Whereas, most cancer research data come from high-profile academic centers, little is known about the outcomes of cancer care in rural communities. We summarize the experience of building a multi-institution partnership to develop a cancer outcomes research infrastructure in Southwest Georgia (SWGA), a primarily rural 33-county area with over 700,000 residents. The partnership includes eight institutions: the Emory University in Atlanta, the Centers for Disease Control and Prevention (CDC), the Georgia Comprehensive Center Registry (the Registry), the Southwest Georgia Cancer Coalition (the Coalition), and the four community cancer centers located within the SWGA region. The practical application of the partnership model, its organizational structure, and lessons learned are presented using two specific examples: a study evaluating treatment decisions and quality of life among prostate cancer patients, and a study of treatment discontinuation among prostate, breast, lung, and colorectal cancer patients. Our partnership model allowed us to (1) use the Coalition as a link between Atlanta-based researchers and local community; (2) collaborate with the area cancer centers on day-to-day study activities; (3) involve the Registry personnel and resources to identify eligible cancer cases and to perform data collection; and (4) raise community awareness and sense of study ownership through media announcements organized by the Coalition. All of the above activities were performed in consultation with the funding institution (CDC) and its project directors who oversee several other studies addressing similar research questions throughout the country. Our partnership model may provide a useful framework for cancer outcomes research projects in rural communities.
PMCID: PMC3697054  PMID: 18850070
Cancer; Rural population; Outcomes research; Partnership

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