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1.  Cognitive and affective influences on perceived risk of ovarian cancer† 
Psycho-oncology  2014;24(3):279-286.
Studies suggest that both affective and cognitive processes are involved in the perception of vulnerability to cancer and that affect has an early influence in this assessment of risk. We constructed a path model based on a conceptual framework of heuristic reasoning (affect, resemblance, and availability) coupled with cognitive processes involved in developing personal models of cancer causation.
From an eligible cohort of 16 700 women in a managed care organization, we randomly selected 2524 women at high, elevated, and average risk of ovarian cancer and administered a questionnaire to test our model (response rate 76.3%). Path analysis delineated the relationships between personal and cognitive characteristics (number of relatives with cancer, age, ideas about cancer causation, perceived resemblance to an affected friend or relative, and ovarian cancer knowledge) and emotional constructs (closeness to an affected relative or friend, time spent processing the cancer experience, and cancer worry) on perceived risk of ovarian cancer.
Our final model fit the data well (root mean square error of approximation (RMSEA) = 0.028, comparative fit index (CFI) = 0.99, normed fit index (NFI) = 0.98). This final model (1) demonstrated the nature and direction of relationships between cognitive characteristics and perceived risk; (2) showed that time spent processing the cancer experience was associated with cancer worry; and (3) showed that cancer worry moderately influenced perceived risk.
Our results highlight the important role that family cancer experience has on cancer worry and shows how cancer experience translates into personal risk perceptions. This understanding informs the discordance between medical or objective risk assessment and personal risk assessment.
PMCID: PMC4522899  PMID: 24916837
2.  Characteristics associated with genetic counseling referral and BRCA1/2 testing among women in a large integrated health system 
Evidence shows underutilization of cancer genetics services. To explore the reasons behind this underutilization, this study evaluated characteristics of women who were referred for genetic counseling and/or had undergone BRCA1/2 testing.
An ovarian cancer risk perception study stratified 16,720 eligible women from the Henry Ford Health System into average-, elevated-, and high-risk groups based on family history. We randomly selected 3,307 subjects and interviewed 2,524 of them (76.3% response rate).
Among the average-, elevated-, and high-risk groups, 2.3, 10.1, and 20.2%, respectively, reported genetic counseling referrals, and 0.8, 3.3, and 9.5%, respectively, reported having undergone BRCA testing. Personal breast cancer history, high risk, and perceived ovarian cancer risk were associated with both referral and testing. Discussion of family history with a doctor predicted counseling referral, whereas belief that family history influenced risk was the strongest BRCA testing predictor. Women perceiving their cancer risk as much higher than other women their age were twice as likely (95% confidence interval: 2.0–9.6) to report genetic counseling referral.
In a health system with ready access to cancer genetic counseling and BRCA testing, women who were at high risk underutilized these services. There were strong associations between perceived ovarian cancer risk and genetic counseling referral, and between a belief that family history influenced risk and BRCA testing.
PMCID: PMC4522900  PMID: 24946155
BRCA1 and BRCA2 genes; family history; genetic counseling; genetic testing; hereditary breast and ovarian cancer syndrome
3.  A Trial of Family Partnership and Education Interventions in Heart Failure 
Journal of cardiac failure  2013;19(12):10.1016/j.cardfail.2013.10.007.
Lowering dietary sodium and adhering to medication regimens are difficult for persons with heart failure (HF). Because these behaviors often occur within the family context, this study evaluated the effects of family education and partnership interventions on dietary sodium (NA) intake and medication adherence (MA).
HF patients and family member (FM) dyads (N = 117) were randomized to: usual care (UC), Patient-FM education (PFE), or a family partnership intervention (FPI). Dietary NA (3-day food record), Urine NA (24-hour urine) and MA (MEMS®) were measured at baseline (BL) prior to randomization, and at 4 and 8 months (M).
FPI and PFE reduced Urine NA at 4 M, and FPI differed from UC at 8 M (p=.016). Dietary NA decreased from BL to 4M with both PFE (p=.04) and FPI (p=.018) lower than UC. The proportion of subjects adherent to NA intake (≤ 2500 mg/day) was higher at 8 M in PFE and FPI vs UC (χ2(2)=7.076, p=.029). MA did not differ among groups across time. Both FPI and PFE groups increased HF knowledge immediately after intervention.
Dietary NA intake, but not MA, was improved by the PFE and FPI interventions compared with UC. UC was less likely to be adherent with dietary NA. Greater efforts to study and incorporate family-focused education and support interventions into HF care are warranted.
PMCID: PMC3869235  PMID: 24331203
self management; adherence; dietary sodium; medication adherence; autonomy support
4.  Perpetration of physical and sexual abuse and subsequent fathering of pregnancies among a cohort of young South African men: a longitudinal study 
BMC Public Health  2014;14:947.
Young men’s involvement in fathering pregnancies has been substantially neglected in unintended pregnancy research. Gender norms give men substantial power and control over sexual encounters, suggesting that understanding men’s role is imperative. We tested the hypothesis that young, unmarried South African men who had perpetrated intimate partner violence (IPV) have a greater incidence of fathering pregnancies.
The data for this study were collected from 983 men aged 15 to 26 who participated in a 2-year community randomized controlled HIV prevention trial in the rural Eastern Cape. Multivariate Poisson models investigated the associations between baseline perpetration of IPV and fathering subsequent pregnancies, while controlling for age, number of sexual partners, socio-economic status, educational attainment, problematic alcohol use, exposure to the intervention, and time between interviews.
Of the men in this study, 16.5% (n = 189) had made a girlfriend pregnant over two years of follow up. In addition, 39.1% had perpetrated physical or sexual intimate partner violence and 24.3% had done so more than once. Men who at baseline had perpetrated IPV in the previous year had an increased incidence of fathering, for a first perpetration in that year IRR 1.67 (95% CI 1.14-2.44) and among those who had also been previously violent, IRR 1.97 (95% CI 1.31-2.94). Those who had ever been violent, but not in the past year, did not have an elevated incidence. The incidence among men who had ever perpetrated physical abuse was less elevated than among those who had perpetrated physical and sexual violence IRR 1.64 (95% CI 1.18-2.29) versus IRR 2.59 (95% CI 1.64-4.10) indicating a dose response.
Young men’s perpetration of partner violence is an important predictor of subsequently fathering a pregnancy. The explanation may lie with South African hegemonic masculinity, which valorizes control of women and displays of heterosexuality and virility, and compromises women’s reproductive choices.
PMCID: PMC4177689  PMID: 25214147
Intimate partner violence perpetration; Paternity; Teenage pregnancy; South Africa
5.  Risk factors for unplanned and unwanted teenage pregnancies occurring over two years of follow-up among a cohort of young South African women 
Global Health Action  2014;7:10.3402/gha.v7.23719.
Although teenage pregnancies in South Africa have declined, the short and longer term health and social consequences are a potential public health concern. This longitudinal study aimed to describe the range of risk and protective factors for incident unwanted and unplanned pregnancies occurring over 2 years of follow-up among a cohort of adolescent women in the Eastern Cape, South Africa. It also investigated the relationship between gender inequality and gender-based violence and subsequent unplanned and unwanted pregnancies among the cohort.
Teenage girls, aged 15–18 years (n=19), who were volunteer participants in a cluster randomized controlled trial and who had data from at least one follow-up were included in this analysis. To assess risk and protective factors for incident unwanted or unplanned pregnancies, we constructed multivariate polytomous regression models adjusting for sampling clusters as latent variables. Covariates included age, having a pregnancy prior to baseline, education, time between interviews, study intervention arm, contraceptive use, experience of intimate partner violence, belief that the teenage girl and her boyfriend are mutual main partners, and socioeconomic status.
Overall, 174 pregnancies occurred over the 2-year follow-up period. Beliefs about relationship control were not associated with unwanted and unplanned pregnancies, nor were experiences of forced first sex or coerced sex under the age of 15. Hormonal contraception was protective against unplanned pregnancies (OR 0.40; 95% CI 0.21–0.79); however, using condoms was not protective. Physical abuse (OR 1.69; 95% CI 1.05–2.72) was a risk factor for, and having a pregnancy prior to baseline was protective against an unwanted pregnancy (OR 0.25; 95% CI 0.07–0.80). Higher socioeconomic status was protective for both unplanned and unwanted pregnancies (OR 0.69; 95% CI 0.58–0.83 and OR 0.78; 95% CI 0.64–0.96). Believing that the teenage girl and her boyfriend were mutual main partners doubled the odds of reporting both an unplanned and unwanted pregnancy (OR 2.58 95% CI 1.07–6.25, and OR 2.21 95% CI 1.13–4.29).
Although some of the measures of gender inequity were not associated with unplanned and unwanted pregnancies, there is evidence of the role of both gender power and socioeconomic status. This was evident in teenage girls who experienced physical violence being more likely to have an unwanted pregnancy. Interventions to prevent teenage pregnancies need to be tailored by socioeconomic status because some teenagers may see having a pregnancy as a way to have a more secure future. Interventions that engage with relationship dynamics of teenagers are essential if unwanted and unplanned pregnancies are to be prevented.
PMCID: PMC4141943  PMID: 25150027
unplanned pregnancy; unwanted pregnancy; adolescent pregnancy; gender-based violence; South Africa
6.  Condoms “contain worms” and “cause HIV” in Tanzania: Negative Condom Beliefs Scale development and implications for HIV prevention 
Social science & medicine (1982)  2012;75(9):1685-1691.
Condom promotion remains a key component of HIV prevention programs, complimenting recent successes in biomedical HIV prevention. Although condom use has increased in much of East Africa, it remains substantially below optimal levels. Negative rumors about condoms have been documented in East Africa, yet the prevalence and effects of belief in the negative rumors have not been explored. This study evaluated levels of belief in negative rumors about condoms, developed a Negative Condom Beliefs Scale, and assessed its accuracy in predicting willingness to use condoms. A cross-sectional, cluster survey (n=370) was conducted representing adults in two rural districts in Northern Tanzania in 2008. Item agreement ranged from 35–53% for the following rumors regarding condoms: causing cancer, having holes, containing HIV, having worms, and the worms causing HIV. Items loaded on a single latent factor and had high internal consistency and convergent validity. In a multivariate model, negative condom score (AOR=0.67, 95% CI=0.6, 0.8) was the strongest single predictor of willingness to use condoms, followed by greater perceived anonymity in acquiring condoms (AOR=4.36, 95% CI=2.2, 8.6) and higher condom self-efficacy (AOR=4.24, 95% CI=2.0, 8.9). Our findings indicate high levels of subscription to negative beliefs about condoms, with two out of three respondents affirming belief in at least one negative condom rumor. This study highlights the relation between condom rumor beliefs and willingness to use condoms, and indicates avenues for future research and means for improving the design of HIV prevention programs.
PMCID: PMC3432708  PMID: 22877934
HIV; prevention; condoms; Africa; Tanzania; behavioral research; survey research
7.  Excessive Drinking Among African American Men: Individual and Contextual Correlates 
In this paper we explored associations of multiple domains with regular drinking and getting drunk among adult African American men. Questionnaire-based, computer-assisted interviews were conducted with 484 men in Atlanta, Georgia. Data analysis involved multivariate logistic regression analyses. Findings show that being older increased the odds of both drinking behaviors. Sensation seeking increased the odds of regular drinking and having experienced childhood sexual and physical abuse increased the odds of getting drunk. Having health insurance reduced the odds of both outcomes. Insurance coverage and the heterogeneity among adult African American men must be considered in risk reduction efforts.
PMCID: PMC3391578  PMID: 22679893
Alcohol; African American; Men
8.  Prevalence and predictors of complementary and alternative medicine use in African-Americans with acquired immune deficiency syndrome 
The use of complementary and alternative medicine (CAM) among Human Immunodeficiency Virus (HIV)-positive individuals is becoming increasingly widespread. Unfortunately, some CAM therapies may jeopardize the efficacy of conventional HIV medication, making it critical to understand CAM use among this population.
To investigate the prevalence and predictors of CAM use in a theory-driven, multidimensional manner.
African-American individuals who had received a diagnosis of acquired immune deficiency syndrome (AIDS) were recruited. The computer-administered survey asked questions about participants’ CAM use and various psychosocial and socio-demographic characteristics. Participants’ most recent CD4+ cell counts and HIV RNA levels were abstracted from medical records. Linear regression analyses, adjusted for potential confounders, were conducted to assess the independent contribution of various factors in explaining frequency of CAM use.
One hundred and eighty two subjects participated in the survey. Results indicate that most (94%) participants used at least one type of CAM therapy. The majority of participants (79.7%) used CAM therapies as a complement (rather than an alternative) to their HIV medications though half had not discussed these therapies with their healthcare providers. Female sex, high yearly income, high health literacy and high HIV RNA levels were associated with a greater frequency of CAM use, while stronger emotional well-being was associated with a lower frequency of CAM use.
The implications of these findings are discussed and suggestions for future research are provided.
PMCID: PMC3346672  PMID: 22577340
African-American; Complementary and alternative medicine; HIV/AIDS
9.  Recruiting Women for a Study on Perceived Risk of Cancer: Influence of Survey Topic Salience and Early Versus Late Response 
Understanding the characteristics of early and late survey responders has implications for recruitment efforts and for informing potential response bias. The main objective of this analysis was to examine survey responder status (ie, early vs late response) by sociodemographic characteristics and by salience of study variables among respondents.
We analyzed data from a survey on family cancer history and perceived cancer risk among women at a large managed health-care organization. For baseline and 12-month follow-up surveys, we defined early versus late responder status according to the 95th percentile of the number of days it took to obtain completed interviews.
We found no significant associations between responder status and sociodemographic characteristics at baseline or follow-up. At baseline, early responders were significantly more likely than late responders to have a personal history of breast cancer (5.2% vs 3.4%, P = .04) and to have been referred for genetic counseling (4.6% vs 2.0%, P = .004). The association between personal history of breast cancer and responder status persisted at follow-up; only 3.5% of late responders at baseline were also late responders at follow-up. Follow-up survey nonresponse rates did not vary by baseline responder status.
Survey topic salience is associated with early response and is important for recruitment. However, once recruited, late responders do not remain late responders at follow-up, suggesting that extra efforts made to recruit late responders are worthwhile. Health-related agencies that conduct surveys should consider survey salience in survey administration and recruitment strategies.
PMCID: PMC3664209  PMID: 23660117
10.  Feasibility Study of Social Media to Reduce Intimate Partner Violence Among Gay Men in Metro Atlanta, Georgia 
Intimate Partner Violence (IPV) is a major public health issue occurring in the United States and globally. While little is known in general about IPV, understanding about the prevalence of physical IPV among gay men is even more obscure. There is a clear disparity in violence research attention focused on this vulnerable segment of society. This cross-sectional survey study was conducted to examine the feasibility of enrolling 100 gay men from Atlanta into an IPV survey study. The survey was administered via Facebook. Ninety-nine usable surveys were collected. Chi-square tests reveal that minority ethnic status, illicit drug use, and non-disclosed orientation status were all significantly associated with positive IPV reports--in terms of both victimization as well as perpetration. Overall, the majority of the study sample indicated that they believe IPV is a health problem in the Atlanta gay community. These findings bear importance for the Atlanta gay community and public health professionals who must address this nearly invisible yet increasing public health issue.
PMCID: PMC3426372  PMID: 22928060
11.  Adherence, Sexual Risk, and Viral Load in HIV-Infected Women Prescribed Antiretroviral Therapy 
AIDS Patient Care and STDs  2011;25(7):431-438.
The purpose of this study was to determine if there was a connection between adherence to antiretroviral therapy (ART) and use of risk reduction behaviors (RRB) in HIV-infected women who were prescribed antiretroviral therapy. The sample consisted of 193 predominately African American women with an average age of 44 who had been on ARV for approximately 9 years and had low annual incomes. All women were participating in a behavioral clinical trial focused on these dual outcomes. Using a risk index developed for this study, we examined the relationship of a composite of risk behaviors to electronically measured and self-reported adherence over the approximately 13-month study period. Women were categorized based on levels of adherence and risky behaviors, and we sought to determine if these classifications were associated with clinical outcomes of HIV viral load and CD4 counts. High levels of adherence were correlated with low risk behaviors (abstinence, consistent use of condoms, etc.). Those classified as high adherence and low-risk behavior (HALR) as well as those classified as high adherence and high-risk behavior (HAHR) had lower mean viral loads and higher CD4 counts than those in the other categories. Women in the low adherence and high-risk category (LAHR) had detectable viral loads and the lowest CD4 counts and are at higher risk for transmitting HIV to partners and unborn children. Our findings underscore the importance of addressing adherence to both ART and RRB in HIV clinical settings to improve clinical outcomes and reduce HIV transmission.
PMCID: PMC3125575  PMID: 21663541
12.  Validity of Self-Reported Solar UVR Exposure Compared to Objectively Measured UVR Exposure 
Reliance on verbal self-report of solar exposure in skin cancer prevention and epidemiologic studies may be problematic if self-report data are not valid due to systematic errors in recall, social desirability bias, or other reasons.
This study examines the validity of self-reports of exposure to ultraviolet radiation (UVR) compared to objectively measured exposure among children and adults in outdoor recreation settings in four regions of the United States. Objective UVR exposures of 515 participants were measured using polysulfone film badge UVR dosimeters on two days. The same subjects provided self-reported UVR exposure data on surveys and 4-day sun exposure diaries, for comparison to their objectively measured exposure.
Dosimeter data showed that lifeguards had the greatest UVR exposure (24.5% of weekday ambient UVR), children the next highest exposures (10.3% ambient weekday UVR) and parents had the lowest (6.6% ambient weekday UVR). Similar patterns were observed in self-report data. Correlations between diary reports and dosimeter findings were fair to good and were highest for lifeguards (r = 0.38 – 0.57), followed by parents (r = 0.28 – 0.29) and children (r = 0.18 – 0.34). Correlations between survey and diary measures were moderate to good for lifeguards (r = 0.20 – 0.54) and children (r = 0.35 – 0.53).
This is the largest study of its kind to date, and supports the utility of self-report measures of solar UVR exposure.
Overall, self-reports of sun exposure produce valid measures of UVR exposure among parents, children, and lifeguards who work outdoors.
PMCID: PMC3005549  PMID: 20940277
skin cancer; sun exposure; UVR; dosimeters; validation; biomarkers
13.  Psychosocial Predictors of Lifestyle Management In Adults with Epilepsy 
Epilepsy & behavior : E&B  2008;13(3):523-528.
The purpose of this article is to describe a test of psychosocial variables predicting lifestyle management among people with epilepsy. The variables selected for the model were based on social cognitive theory and the results of previous studies examining psychosocial predictors of self-management among people with chronic physical health conditions. Variables included in the model were self-efficacy, outcome expectancies, depressive symptoms, and social support. Participants for the study were recruited from epilepsy treatment facilities in Boston, MA and Atlanta, GA. Half of the participants were female, 81% were white, and their mean age was 43.1 years. As predicted by social cognitive theory, self-efficacy was related to lifestyle management and explained 23% of its variation. Depressive symptoms were related to both self-efficacy and social support. Social support was related to self-efficacy. These findings suggest that lifestyle management is influenced by a number of relationships between psychosocial variables, particularly by self-efficacy.
PMCID: PMC3150734  PMID: 18595777
14.  A Survey of Georgia Adult Protective Service Staff: Implications for Older Adult Injury Prevention and Policy 
The aging population is a rapidly growing demographic. Isolation and limited autonomy render many of the elderly vulnerable to abuse, neglect and exploitation. As the population grows, so does the need for Adult Protective Services (APS). This study was conducted to examine current knowledge of older adult protection laws in Georgia among APS staff and to identify training opportunities to better prepare the APS workforce in case detection and intervention.
The Georgia State University Institute of Public Health faculty developed a primary survey in partnership with the Georgia Division of Aging Services’ leadership to identify key training priority issues for APS caseworkers and investigators. A 47-item electronic questionnaire was delivered to all APS employees via work-issued email accounts. We conducted descriptive analyses, t-tests and chi-square analyses to determine APS employees’ baseline knowledge of Georgia’s elder abuse policies, laws and practices, as well as examine associations of age, ethnicity, and educational attainment with knowledge. We used a p-value of 0.05 and 95% confidence intervals to determine statistical significance of analyses performed.
Ninety-two out of 175 APS staff responded to the survey (53% response rate). The majority of respondents were Caucasian (56%) women (92%). For over half the survey items, paired sample t-tests revealed significant differences between what APS staff reported as known and what APS staff members indicated they needed to know more about in terms of elder abuse and current policies. Chi-square tests revealed that non-Caucasians significantly preferred video conferencing as a training format (44% compared to 18%), [χ2(1) = 7.102, p < .008], whereas Caucasians preferred asynchronous online learning formats (55% compared to 28%) [χ2(1) =5.951, p < .015].
Results from this study provide the Georgia Division of Aging with insight into specific policy areas that are not well understood by APS staff. Soliciting input from intended trainees allows public health educators to tailor and improve training sessions. Trainee input may result in optimization of policy implementation, which may result in greater injury prevention and protection of older adults vulnerable to abuse, neglect and exploitation.
PMCID: PMC3117614  PMID: 21731795
15.  Adherence to Antiretroviral Medication Regimens: A Test of a Psychosocial Model 
AIDS and behavior  2007;13(1):10-22.
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.
PMCID: PMC3104939  PMID: 17978868
AIDS; Medication adherence; Antiretroviral medication
16.  Development and Evaluation of a Complementary and Alternative Medicine Use Survey in African-Americans with Acquired Immune Deficiency Syndrome 
The purpose of the current study was to develop and evaluate the psychometric properties of a culturally- and stage-of-disease-appropriate measure of complementary and alternative medicine (CAM) use among a population of African-American individuals with acquired immune deficiency syndrome (AIDS) using a mixed-method design.
Data were collected in two phases. In phase 1, qualitative data were used to refine an existing CAM measure for the specific study population in the present study. In phase 2, this refined instrument was implemented in a larger sample. The resulting numeric data were analyzed to evaluate the psychometric properties of the revised CAM instrument.
Data were collected from patients who were receiving care from the infectious disease clinic of a large, public, urban hospital in the Southeastern United States.
Patients were eligible to participate if they (1) were receiving their care from the clinic, (2) had an AIDS diagnosis, (3) were identified as African-American, (4) were ≥21 years of age, (5) spoke English, and (6) were not cognitively impaired.
Focus groups in phase 1 were conducted with a semistructured focus group guide. Participants also completed a basic sociodemographic survey. Phase 2 participants used programmed laptops to answer questions about their CAM use and several sociodemographic questions.
Information from the focus groups prompted some substantive revisions in the already-existing CAM survey. The revised instrument had satisfactory face validity and adequate test–retest reliability (r = 0.79). Furthermore, the instrument factored in a manner that was interpretable and consistent with prior findings.
In order for human immunodeficiency virus health care providers to provide the best care to their patients, they need to be informed about the types and frequency of CAM use among their patients. This can be accomplished by methodologically developing CAM instruments, rigorously implementing and assessing these instruments, and then disseminating the findings to researchers and practitioners.
PMCID: PMC3110866  PMID: 20455786
17.  An Examination of the Psychometric Properties of the Antiretroviral General Adherence Scale (AGAS) in Two Samples of HIV-Infected Individuals 
This paper reports on the development and psychometric properties of the Antiretroviral General Adherence Scale (AGAS) in 2 NIH-funded projects: the Get Busy Living Project, a behavioral clinical trial to promote consistent use of antiretroviral therapy (ART); and the KHARMA Project, which addressed issues of adherence and risk reduction behavior in women. AGAS assesses the ease and ability of participants to take ART according to a health care provider's recommendations. Data were analyzed from completed baseline assessments of the 2 studies. The AGAS was internally consistent in both samples. Content, construct, and criterion validity were established using factor analysis and correlations of total AGAS scores with 2 measures of adherence: electronic drug monitoring (EDM) and an Adult AIDS Clinical Trials Group (AACTG) adherence scale. Viral load, CD4 cell counts, and depression scores were also examined. Reliability and validity of the AGAS were supported in both samples.
PMCID: PMC2826579  PMID: 19804994
adherence; antiretroviral medications; reliability; psychometrics; validity
18.  Serum vitamin D concentrations are related to depression in young adult US population: the Third National Health and Nutrition Examination Survey 
Vitamin D receptors have been mapped throughout the brain suggesting a role for vitamin D in psychosomatic disorders. Results from previous epidemiological studies on relation between vitamin D status and depression are equivocal. Also, limited information is available relating vitamin D status with depression in young adult US population.
Data from the third National Health and Nutrition Examination Survey were used to assess association between serum vitamin D and depression in 7970 non-institutionalized US residents, aged 15-39 y. Assessment of depression was done using the Diagnostic Interview Schedule developed by the National Institute of Mental Health. After accounting for several confounding variables in multivariate logistic regression analysis, we estimated odds ratios (OR) for having depression in vitamin D deficient persons in comparison to vitamin D sufficient persons.
Women, non-Hispanic blacks, persons living below poverty, persons who did not consume supplements, persons living in South and West regions and in urban areas, persons with higher BMI, and persons with current depression had higher prevalence of vitamin D deficiency compared to their counterparts. OR for having current depressive episodes in persons with serum vitamin D ≤ 50 nmol/L is significantly higher relative to those with serum vitamin D ≥ 75 nmol/L (OR = 1.85; P = 0.021).
In this large population based study, likelihood of having depression in persons with vitamin D deficiency is significantly higher compared to those with vitamin D sufficiency. Early diagnosis and intervention are paramount because coexistence of vitamin D deficiency and depression has serious negative consequences on health.
PMCID: PMC2996356  PMID: 21067618
Psychological responses have been reported for some patients after insertion of an implantable cardioverter defibrillator (ICD). This study tested the effects of a psychoeducational intervention on anxiety, depressive symptoms, functional status and health resource use during the first year after ICD implantation.
ICD patients (n=246) were randomized to usual care (UC), group (GRP), or telephone counseling (TC) intervention that included education, symptom management, and coping skill training. Participants were 58 ± 11 years, 73% men, and 23% minorities. Anxiety (STAI), depressive symptoms (BDI-II), and functional status (DASI) were measured at baseline and after 1, 3, 6 & 12 months. Health resource use and disability days were tracked. Analyses were repeated-measures ANCOVA to assess Group X Time effects, Chi-square for percentage with clinically significant anxiety and depression at each time point, and logistic regression.
All groups experienced decreased anxiety and depressive symptoms over the 12 months; GRP intervention had lower STAI (p=.03) than UC at 3 months. Logistic regression revealed group differences for predicted probability of having depressive symptoms at 12 months (UC=.31, GRP=.17, TC=.13, p=.03). UC had greater calls to providers at 1 and 6 months (p<.05) and more sick/disability days at 12 months (p=.01) than intervention groups.
A psychoeducational intervention reduced anxiety and depressive symptoms early after ICD, lowered probability of depressive symptoms at one year, and decreased disability days/calls to providers. These findings support further study and clinical use of both group and telephone interventions to yield better psychological outcomes after ICD implant.
PMCID: PMC2757745  PMID: 19796343
VT; Defibrillation - ICD; Quality of Life
20.  Lifeguards’ Sun Protection Habits and Sunburns 
Archives of dermatology  2009;145(2):139-144.
To examine associations among outdoor pool environments, social norms, pool policies, and participation in a sun safety program with lifeguards’ sun protection habits and sunburn.
Cross-sectional survey.
Outdoor swimming pools across the United States.
Lifeguards and aquatic instructors at pools participating in the Pool Cool skin cancer prevention program in 2001 (N=699) and 2002 (N=987).
Main Outcome Measures
Sun protection habits and number of sunburns.
Social norms supporting sun safety were associated with more sun protection habits (95% confidence intervals [CIs], 0.18–0.28 in 2001 and 0.17–0.26 in 2002), as were pool policies supporting sun safety (95% CI, 0.02–0.07 in 2001 and 0.002–0.04 in 2002). There was a trend toward fewer sunburns as social norms, pool policies, and participation in the Pool Cool program increased, but results differed across the 2 years. In 2001, lower social norms scores and pool policy scores were associated with more reported sunburns. In 2002, teaching Pool Cool sun safety lessons was associated with fewer sunburns.
The pool environment is related to sun safety behaviors of outdoor pool staff, with social norms showing the strongest association.
PMCID: PMC2928139  PMID: 19221258
21.  Children at Risk for Suicide Attempt and Attempt-related Injuries: Findings from the 2007 Youth Risk Behavior Survey 
The current study examines the associations between a range of risk factors and reports of suicide attempts and attempts requiring medical care in a nationally representative study of high school students. The goal is to examine sex differences in the risk factors associated with suicide attempts and attempt-related injuries requiring treatment by a health-care provider.
We used data from the 2007 Youth Risk Behavior Survey for students in grades 9–12 to assess the prevalence and risk factors for suicidal behavior, as well as differences in these for boys and girls. Cross-sectional multivariate logistic regression analyses were computed to determine the most important risk factors for suicide attempts and for suicide attempts requiring medical care for the sample overall and also stratified for boys and for girls.
Overall, 6.9% of adolescents attempted suicide (9.3% of girls versus 4.6% of boys). Girls were more likely than boys to report a suicide attempt in the past year (Adj.OR=2.89). Among girls, sadness (Adj.OR=5.74), weapon carrying (Adj.OR=1.48), dating violence (Adj.OR=1.60), forced sex (Adj.OR=1.72), and huffing glue (Adj.OR=2.04) were significantly associated with suicide attempts. Among boys, sadness (Adj.OR=10.96), weapon carrying (Adj.OR=1.66), forced sex (Adj.OR=2.60), huffing glue (OR=1.63), hard drug use (Adj.OR=2.18), and sports involvement (Adj.OR=1.52) were significantly associated with suicide attempts.
These findings demonstrate similarities and differences in the modifiable risk factors that increase risk for suicide attempts among boys and girls. In terms of the differences between boys and girls, hard drug use and sports involvement may be important factors for suicide-prevention strategies directed specifically towards boys, while dating violence victimization may be an important risk factor to address for girls. Overall, these findings can help guide prevention, clinical practice, and intervention strategies to prevent suicidal behaviors among adolescents.
PMCID: PMC2941363  PMID: 20882146
22.  Development, Psychometric Testing, and Revision of the Atlanta Heart Failure Knowledge Test 
Background and Research Objective
Several heart failure (HF) knowledge tools have been developed and tested over the past decade; however, they vary in content, format, psychometric properties, and availability. This article details the development, psychometric testing, and revision of the Atlanta Heart Failure Knowledge Test (A-HFKT) as a standardized instrument for both the research and clinical settings.
Participants and Methods
Development and psychometric testing of the A-HFKT were undertaken with 116 New York Heart Association (NYHA) class II and III community-dwelling HF patients and their family members (FMs) participating in a family intervention study. Internal consistency, reliability, and content validity were examined. Construct validity was assessed by correlating education level, literacy, dietary sodium ingestion, medication adherence, and healthcare utilization with knowledge.
Content validity ratings on relevance and clarity ranged from 0.55 to 1.0, with 81% of the items rated from 0.88 to 1.0. Cronbach α values were .84 for patients, .75 for FMs, and .73 for combined results. Construct validity testing revealed a small but significant correlation between higher patient and FM knowledge on sodium restriction questions and lower ingested sodium, r = −0.17, P = .05 and r = −0.19, P = .04, respectively, and between patient knowledge and number of days that medications were taken correctly (diuretics: r = 0.173, P < .05, and angiotensin-converting enzyme: r = 0.223, P = .01). Finally, patients seeking emergency care or requiring hospitalization in the 4 months before study entry were found to have significantly lower FM knowledge using both t test and logistic regression modeling.
The A-HFKT was revised using the content and construct validity data and is available for use with HF patients and FMs. The construct validity testing indicates that patient knowledge has a significant relationship to aspects of self-care. Furthermore, family knowledge may influence patient adherence with sodium restriction and healthcare utilization behavior.
PMCID: PMC2828039  PMID: 19858959
education; heart failure; knowledge
23.  Validity of Self-Reported Sunscreen Use by Parents, Children, and Lifeguards 
Verbal self-report is the method most often used to assess sunscreen use, but the data may be confounded by recall error and social desirability. Sunscreen swabbing is a non-invasive procedure to objectively assess the presence of sunscreen on the skin. This study examined the agreement between verbal reports of sunscreen use from survey and diary measures and objectively measured sunscreen use.
Participants were 564 parents, children aged 5–10 years, and lifeguards at 16 swimming pools in four regions of the U.S. Participants completed self-reported measures, including baseline and final surveys, as well as a 4-day diary and objective swabbing measures of sunscreen presence on 2 separate days. Data were collected in 2006 and analyzed in 2006–2007.
Levels of sunscreen use were relatively high based on surveys (65.7%); diary data (40.3%); and swabbing measures (59.1%). Agreement between swabbing and diary measures of sunscreen use was fair to good, with κ statistics for children at 0.40, followed by lifeguards at 0.34 and parents at 0.27. Validity coefficients across measures of sunscreen use were higher for lifeguards and parents than for children, and diary measures were higher than surveys. No systematic errors were found across groups or by gender, latitude, study arm, or risk category.
These findings are comparable to those in other validation studies, including studies of the validity of dietary assessments. Self-reported estimates of sunscreen use by diaries or surveys appear to be as good as objective measures.
PMCID: PMC2626407  PMID: 18945582
24.  Interpret results with caution 
PMCID: PMC2696531  PMID: 19546463
25.  WebEase: Development of a Web-Based Epilepsy Self-Management Intervention 
Preventing Chronic Disease  2008;6(1):A28.
People with epilepsy must adopt many self-management behaviors, especially regarding medication adherence, stress management, and sleep quality. In response to the need for theory-based self-management programs that people with epilepsy can easily access, the WebEase Web site was created and tested for feasibility, acceptability, and usability. This article discusses the theoretical background and developmental phases of WebEase and lessons learned throughout the development process. The WebEase research team developed content for the Web site on the basis of social cognitive theory, the transtheoretical model of behavior change, and motivational interviewing. Formative research and development of the WebEase program included a literature search, computer use survey, a focus group, and review by content experts and consumers. The program has 2 main components: 1) the modules, which provide a tailored opportunity for learning, reflection, and goal setting, and 2) MyLog, a place to enter daily information.
PMCID: PMC2644585  PMID: 19080034

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