Search

Introduction The annual economic burden of chronic homelessness in the U.S. is estimated to be as high as $3.4 billion. The Permanent Supportive Housing with Housing First (Housing First) program, implemented to address the problem, has been shown to be effective. This paper examines the economic cost and benefit of Housing First Programs. Methods The search of peer-reviewed and gray literature from inception of databases through November 2019 yielded 20 evaluation studies of Housing First Programs, 17 from the U.S. and 3 from Canada. All analyses were conducted from March 2019 through July 2020. Monetary values are reported in 2019 U.S. dollars. Results Evidence from studies conducted in the U.S. was separated from those conducted in Canada. The median intervention cost per person per year for U.S. studies was $16,479, and for all studies, including those from Canada, it was $16,336. The median total benefit for the U.S. studies was $18,247 per person per year, and it was $17,751 for all studies, including those from Canada. The benefit-to-cost ratio for U.S. studies was 1.80:1, and for all studies, including those from Canada, it was 1.06:1. Discussion The evidence from this review shows that economic benefits exceed the cost of Housing First Programs in the U.S. There were too few studies to determine cost–benefit in the Canadian context.

An estimated 17-year lag exists between evidence generation and its integration into routine clinical care. The field of implementation science has emerged to close this gap by applying rigorous methods to systematically study the obstacles and facilitators of the uptake of evidence-based practices. However, implementation science has not gained wide traction in dermatology. In this narrative review, we use literature and expert input to introduce implementation science and key frameworks for implementing interventions and evaluating their uptake. We then highlight opportunities for dermatology-specific interventions at the patient-, provider-, system-, and population-levels, and advocate for the field’s expansion into dermatology.

Community Health Centers (CHCs) are a critical source of care for low-income and non-privately insured populations. During the pandemic, CHCs have leveraged their infrastructure and role as a trusted source of care to engage the communities they serve in COVID-19 testing.To directly address the impact that COVID-19 has had on historically marginalized populations in Massachusetts, we designed a study of community-engaged COVID-19 testing expansion: (1) leveraging existing partnerships to accelerate COVID-19 testing and rapidly disseminate effective implementation strategies; (2) incorporating efforts to address key barriers to testing participation in communities at increased risk for COVID-19; (3) further developing partnerships between communities and CHCs to address testing access and disparities; (4) grounding the study in the development of a shared ethical framework for advancing equity in situations of scarcity; and (5) developing mechanisms for communication and science translation to support community outreach. We use a controlled interrupted time series design, comparing number of COVID-19 tests overall and among people identified as members of high-risk groups served by intervention CHCs compared with six matched control CHCs in Massachusetts, followed by a stepped wedge design to pilot test strategies for tailored outreach by CHCs.Here, we describe a community-partnered strategy to accelerate COVID-19 testing in historically marginalized populations that provides ongoing resources to CHCs for addressing testing needs in their communities. The study aligns with principles of community-engaged research including shared leadership, adequate resources for community partners, and the flexibility to respond to changing needs over time.

To evaluate the effectiveness of the Healthy Directions 2 (HD2) intervention in the primary care setting.HD2 was a cluster randomized trial (conducted 3/09-11/11). The primary sampling unit was provider (n=33), with secondary sampling of patients within provider (n=2440). Study arms included: 1) usual care (UC); 2) HD2--a patient self-guided intervention targeting 5 risk behaviors; and 3) HD2 plus 2 brief telephone coaching calls (HD2+CC). The outcome measure was the proportion of participants with a lower multiple risk behavior (MRB) score by follow-up.At baseline, only 4% of the participants met all behavioral recommendations. Both HD2 and HD2+CC led to improvements in MRB score, relative to UC, with no differences between the two HD2 conditions. Twenty-eight percent of the UC participants had improved MRB scores at 6 months, vs. 39% and 43% in HD2 and HD2+CC, respectively (ps≤.001); results were similar at 18 months (p≤.05). The incremental cost of one risk factor reduction in MRB score was $310 for HD2 and $450 for HD2+CC.Self-guided and coached intervention conditions had equivalent levels of effect in reducing multiple chronic disease risk factors, were relatively low cost, and thus are potentially useful for routine implementation in similar health settings.

Background: Association studies have suggested that lower circulating 25-hydroxyvitamin D [25(OH)D] in African Americans may partially underlie higher rates of cardiovascular disease and cancer in this population. Nonetheless, the relation between vitamin D supplementation and 25(OH)D concentrations in African Americans remains undefined. Objective: Our primary objective was to determine the doseresponse relation between vitamin D and plasma 25(OH)D. Design: A total of 328 African Americans in Boston, MA, were enrolled over 3 winters from 2007 to 2010 and randomly assigned to receive a placebo or 1000, 2000, or 4000 IU vitamin D3/d for 3 mo. Subjects completed sociodemographic and dietary questionnaires, and plasma samples were drawn at baseline and 3 and 6 mo. Results: Median plasma 25(OH)D concentrations at baseline were 15.1, 16.2, 13.9, and 15.7 ng/mL for subjects randomly assigned to receive the placebo or 1000, 2000, or 4000 IU/d, respectively (P = 0.63). The median plasma 25(OH)D concentration at 3 mo differed significantly between supplementation arms at 13.7, 29.7, 34.8, and 45.9 ng/mL, respectively (P , 0.001). An estimated 1640 IU vitamin D3/d was needed to raise the plasma 25(OH)D concentration to $20 ng/mL in $97.5% of participants, whe reas ad ose of 4000 IU/d was needed to achieve concentrations $33 ng/mL in $80% of subjects. No significant hypercalcemia was seen in a subset of participants. Conclusions: Within African Americans, an estimated 1640 IU vitamin D3/d was required to achieve concentrations of plasma 25(OH)D recommended by the Institute of Medicine, whereas 4000 IU/d was needed to reach concentrations predicted to reduce cancer and cardiovascular disease risk in prospective observational studies. These results may be helpful for informing future trials of disease prevention. This trial was registered at clinicaltrials.gov as NCT00585637. Am J Clin Nutr 2014;99:587‐98.

Because rates of skin cancer are greater among adult survivors of childhood cancer who received radiation therapy than among the general population, the National Cancer Institute recommends skin self-examinations and annual physician examination. There has been no comprehensive assessment of survivors' adherence to the skin cancer screening guidelines associated with skin self-examination (SSE) and physician whole-body skin examination (PSE). We conducted a cross-sectional survey of radiation-treated, adult 5-year survivors of childhood cancer, diagnosed between 1970 and 1986, in the Childhood Cancer Survivor Study cohort. Multivariate multinomial logit regression investigated the association between demographic, cancer diagnosis, patient activation, cancer treatment characteristics, and skin cancer screening practice. Among 728 survivors, 13.1% reported performing SSE in the prior 2 months plus receiving PSE in the prior 12 months, and 16.4% and 11.0% reported performing only an SSE or a PSE, respectively; 59.5% of survivors reported having had neither. Participants at the highest patient activation score were most likely to report SSE plus PSE compared with neither (adjusted relative risk ratio = 4.16, 95% confidence interval = 1.34-12.85). Most adult survivors of childhood cancer who had radiation therapy do not practice strategies that promote early detection of skin cancer. Interventions designed to activate survivors to increase their participation in screening are needed.

Background Shared decision making (SDM) is a widely recommended yet unproven strategy for increasing colorectal cancer (CRC) screening uptake. Previous trials of decision aids to increase SDM and CRC screening uptake have yielded mixed results. Purpose To assess the impact of decision aid–assisted SDM on CRC screening uptake. Design RCT. Setting/participants The study was conducted at an urban, academic safety-net hospital and community health center between 2005 and 2010. Participants were asymptomatic, average-risk patients aged 50–75 years due for CRC screening. Intervention Study participants ( n =825) were randomized to one of two intervention arms (decision aid plus personalized risk assessment or decision aid alone) or control arm. The interventions took place just prior to a routine office visit with their primary care providers. Main outcome measures The primary outcome was completion of a CRC screening test within 12 months of the study visit. Logistic regression was used to identify predictors of test completion and mediators of the intervention effect. Analysis was completed in 2011. Results Patients in the decision-aid group were more likely to complete a screening test than control patients (43.1% vs 34.8%, p =0.046) within 12 months of the study visit; conversely, test uptake for the decision aid and decision aid plus personalized risk assessment arms was similar (43.1% vs 37.1%, p =0.15). Assignment to the decision-aid arm (AOR=1.48, 95% CI=1.04, 2.10), black race (AOR=1.52, 95% CI=1.12, 2.06) and a preference for a patient-dominant decision-making approach (AOR=1.55, 95% CI=1.02, 2.35) were independent determinants of test completion. Activation of the screening discussion and enhanced screening intentions mediated the intervention effect. Conclusions Decision aid–assisted SDM has a modest impact on CRC screening uptake. A decision aid plus personalized risk assessment tool is no more effective than a decision aid alone. Trial registration This study is registered at www.clinicaltrials.gov NCT00251862.

Prompting may promote engagement with behavior change interventions. Prompts can be delivered inexpensively via automated voice response (AVR) reminders or short message service (SMS) text messages. We examined the association between participants' characteristics and preferred reminder modality.Healthy Directions 2 is a cluster randomized controlled trial implemented in Boston, Massachusetts to promote change in multiple behavioral cancer risk factors. At baseline (2009), participants completed a survey assessing socio-demographics, health status, height/weight, and factors associated with technology. One-third of participants randomized to receive the intervention (n=598) were randomized to receive automated reminders, with participants selecting modality.28% (167/598) of participants selected SMS reminders. Controlling for clustering by primary care provider, younger participants (OR=0.97, 95% CI=(0.95, 0.99), p0.01), those most comfortable with computers (very uncomfortable OR=0.54, 95% CI=(0.29, 1.01), p≤0.05: referent group = very comfortable), and those who frequently sent/received text messages (never OR=0.09 CI=(0.04, 0.16) p0.01; 1-3 times/month OR=0.38, 95% CI=(0.15, 0.93) p=0.04: referent group=1-5 times/week) were more likely to choose SMS.Interventions should make both modalities available to ensure that more participants can benefit from prompting. Studies examining the effect of automated reminders may have reduced effectiveness or generalizability if they employ only one modality.

Smoking cessation among cancer patients is critical for improving outcomes. Understanding factors associated with smoking abstinence after the diagnosis of cancer can provide direction to develop and test interventions to enhance cessation rates. The purpose of this study was to identify determinants of smoking outcomes among cancer patients.Standardized questionnaires were used to collect data from 163 smokers or recent-quitters (quit≤6 months) at study entry of which 132 and 121 had data collected at 3 and 6 months. Biochemical verification was conducted with urinary cotinine and carbon monoxide. Descriptive statistics, Cronbach alpha coefficients, Pearson correlations, Fisher's exact test, and multivariable logistic regression were used for analyses.Seven-day-point-prevalence-abstinence (PPA) rates were 90/132 (68%) at 3 months; 46/71 (65%) among lung and 44/61 (72%) among head and neck cancer patients, whereas 7-day-PPA rates were 74/121 (61%) at 6 months; 31/58 (53%) among lung and 43/63 (68%) among head and neck cancer patients. Continuous abstinence rates were 63/89 (71%) at 3 months; 32/45 (71%) among lung and 31/44 (70%) among head and neck cancer patients, whereas continuous abstinence rates were 46/89 (52%) at 6 months; 18/45 (40%) among lung and 28/44 (64%) among head and neck cancer patients. Lower cancer-related, psychological and nicotine withdrawal symptoms were associated with increased 7-D-PPA abstinence rates at 3 and 6 months in univariate models. In multivariable models, however, decreased craving was significantly related with 7-day-PPA at 3 months and decreased craving and increased self-efficacy were associated with 7-D-PPA at 6 months. Decreased craving was the only factor associated with continuous abstinence at 6 months.Smoking outcomes among lung and head and neck cancer patients appear to have remained the same over the last two decades despite the availability of an increased number of pharmacotherapy options to treat tobacco dependence. Decreased craving and increased self-efficacy were the most consistent factors associated with improved smoking outcomes but symptom control may also play a role in optimal management. Use of combined, and/or higher doses of pharmacotherapy along with behavioral interventions that increase self-efficacy and manage symptoms may promote enhanced cessation rates.

People of lower-socioeconomic position (SEP) and most racial/ethnic minorities face significant communication challenges which may negatively impact their health. Previous research has shown that these groups rely heavily on interpersonal sources to share and receive health information; however, little is known about these lay sources. The purpose of this paper is to apply the concept of a market maven to the public health sector with the aims of identifying determinants of high health information mavenism among low-SEP and racial/ethnic minority groups and to assess the information they may be sharing based on their own health beliefs. Data for this study were drawn from the baseline survey (n = 325) of a US randomized control intervention study aimed at eliciting an understanding of Internet-related challenges among lower-SEP and minority individuals. Regression models were estimated to distinguish significant determinants of health information mavenism among the sample. Similarly, bivariate and logistic multivariable models were estimated to determine the association between health information mavenism and accurate health beliefs relating to diet, physical activity and smoking. The data illustrate that having a larger social network, being female and being older were important factors associated with higher mavenism scores. Additionally being a moderate consumer of general media as well as fewer years in the US and lower language acculturation were significant predictors of higher mavenism scores. Mavens were more likely than non-mavens to maintain accurate beliefs regarding diet; however, there was no distinction between physical activity and smoking beliefs between mavens and non-mavens. These results offer a unique understanding of health information mavenism which could better leverage word-of-mouth health communication efforts among lower-SEP and minority groups in order to reduce communication inequalities. Moreover, the data indicate that health information mavens may serve as an ideal point of intervention in attempts to modify health beliefs with the goal of reducing health disparities among these populations.

Background There are limited data on the effectiveness of skin cancer prevention education and early detection programs at beaches. Objectives We evaluate 4 strategies for addressing skin cancer prevention in beach settings. Methods This prospective study at 4 beaches included 4 intervention conditions: (1) education only; (2) education plus biometric feedback; (3) education plus dermatologist skin examination; or (4) education plus biometric feedback and dermatologist skin examination. Outcomes included sun protection behaviors, sunburns, and skin self-examinations. Results There was a significant increase in hat wearing, sunscreen use, and a reduction in sunburns in the education plus biometric feedback group (odds ratio = 1.97, 1.94, and 1.07, respectively), and greater improvements in knowing what to look for in skin-self examinations (odds ratio = 1.13); there were no differences in frequency of self-examinations. Skin examinations plus biometric feedback led to greater reductions in sunburns. The dermatologist examinations identified atypical moles in 28% of participants. Limitations Inclusion of only one beach per condition, use of self-report data, and a limited intervention period are limitations. Conclusions Education and biometric feedback may be more effective than education alone for impacting sun protective attitudes and behaviors in beachgoing, high-risk populations.

Background Although discrimination has been identified as a potential determinant of existing racial/ethnic health disparities, no studies have investigated whether racial discrimination contributes to disparities in physical activity. Purpose The primary aim of the current study was to examine the association between interpersonal racial discrimination and physical activity. Methods Baseline data were collected during 2004–2005 among a predominately black and Hispanic sample of adult residents living in 12 low-income–housing sites in Boston MA ( n =1055). Residents reported experiences of lifetime racial discrimination during interviewer-administered surveys and wore a pedometer for 5 days to measure physical activity. For analyses, performed in 2009, linear regression models with a cluster design were conducted to predict physical activity, measured as steps per day. Results Nearly 48% of participants reported ever experiencing racial discrimination, and discrimination was most commonly experienced on the street or in a public setting. No association was found between discrimination and physical activity, when examined in bivariate, multivariable, or race-stratified models. Conclusions The current results indicate that self-reported racial discrimination is not a key determinant of physical activity among residents living in low-income housing. However, additional research is warranted to address current limitations of this study.

In the past few decades, significant advances have been made related to understanding, preventing, and treating chronic disease. Given these many advances across multiple disciplines, it is unclear why the potential for yielding substantial reduction in disease has not been achieved overall and across various subgroups. Socioeconomic and racial/ethnic disparities in a wide range of disease outcomes persist, and a number of studies highlight the importance of further improving behavioral risk-factor prevalence on a population level. The goal of this paper is to explore the role of transdisciplinary collaboration in the translation of research related to these vexing public health problems, and, in particular, to explore factors that appear to facilitate effective and sustainable translation. Transdisciplinary collaboration also has great potential to speed the rate of adoption of evidence-based practices. Examples of transdisciplinary collaborations in academic and community settings are provided, along with factors that may influence the long-term outcomes of transdisciplinary efforts.

Community college students represent 44% of all students enrolled in U.S. higher education facilities. To our knowledge, no previous smoking cessation intervention has targeted community college students. Previous studies suggest that a motivational smoking cessation intervention could be successful for young adult smokers. Combining motivational interviewing sessions with personalized health feedback is likely to increase participants’ motivation to quit and movement through the stages of change. The purpose of this study was to evaluate the impact of a smoking cessation program based on these premises. We designed a computer-assisted, counselor-delivered smoking cessation program that addresses personal health risks and readiness to change smoking behavior among community college students. A group-randomized, controlled trial was used to assess the intervention in a sample of 426 students (58.5% females; mean age, 22.8 ± 4.7 years) from 15 pair-matched campuses. At the 10-month follow-up assessment, the cotinine-validated smoking cessation rates were 16.6% in the experimental condition and 10.1% in the standard care condition (p = 0.07). Our results indicate that our computer-assisted intervention holds considerable promise in reducing smoking among community college students.

The manuscript examines the influence of contextual factors on whether and for whom a colon polyp diagnosis might be a teachable moment, as indicated by engagement with a proactively delivered intervention. Baseline and 8-month follow-up data were analyzed from a two-site behavioral intervention trial with patients in Massachusetts and North Carolina, USA who had recently undergone polypectomy for pre-cancerous colon polyps and were randomized to a behavior change intervention condition (N = 591). Intervention “buy-in” was used as an indicator of response consistent with the polyp identification serving as a teachable moment. Cancer worry, personal risk, health-related self-identity and other sociodemographic factors were tested to predict intervention buy-in. As predicted, those who were most worried about colon cancer were most likely to engage in the intervention. One indicator of personal risk, number of risk behaviors, was significantly and negatively associated with buy-in. Predictors of intervention buy-in and cancer worry were not consistent. We recommend that expanded measures of affect and health-related self-identity should be considered in future research to understand the motivational potential of health events for increasing engagement in effective behavior change interventions.

Objective. The use of the news media to disseminate control research could play a pivotal role in reducing the cancer burden. An important first step is to understand how newspapers cover cancer and if differences exist between mainstream and ethnic newspapers. Methods. Cancer news in the major U.S. (MAJN) ( N = 5327) and ethnic (ENW) newspapers ( N = 565) appearing in 2003 were content analyzed. Comparisons of mainstream and ethnic newspapers utilized Pearson × 2 tests of two-sided statistical significance and independent samples t tests for interval-level variables. Results. Breast cancer dominated coverage: 27% of MAJN and 35% of ENW stories mentioned breast cancer. Coverage focused primarily on cancer treatment (MAJN: 60%; ENW: 52%) rather than on primary or secondary prevention. Compared to mainstream newspapers, the ethnic newspapers required lower literacy levels for understanding news stories, were substantially more likely to cover primary and secondary cancer prevention, and paid more attention to cancer awareness and education. Conclusions. The ethnic media are a promising vehicle for dissemination of cancer control messages. However, the successful utilization of any U.S. newspaper as a dissemination mechanism requires a greater understanding of the root causes for imbalances in cancer coverage and work with journalists to reframe cancer news coverage.

Purpose Smoking cessation after myocardial infarction reduces cardiovascular mortality, but many smokers cannot quit despite state-of-the-art counseling intervention. Bupropion is effective for smoking cessation, but its safety and efficacy in hospitalized smokers with acute cardiovascular disease is unknown. Methods A five-hospital randomized double-blind placebo-controlled trial assessed the safety and efficacy of 12 weeks of sustained-release bupropion (300 mg) or placebo in 248 smokers admitted for acute cardiovascular disease, primarily myocardial infarction and unstable angina. All subjects had smoking counseling in the hospital and for 12 weeks after discharge. Cotinine-validated 7-day tobacco abstinence, cardiovascular mortality, and new cardiovascular events were assessed at 3 months (end-of-treatment) and 1 year. Results Validated tobacco abstinence rates in bupropion and placebo groups were 37.1% vs 26.8% (OR 1.61, 95% CI, 0.94-2.76; P =.08) at 3 months and 25.0% vs 21.3% (OR, 1.23, 95% CI, 0.68-2.23, P =.49) at 1 year. The adjusted odds ratio, after controlling for cigarettes per day, depression symptoms, prior bupropion use, hypertension, and length of stay, was 1.91 (95% CI, 1.06-3.40, P =.03) at 3 months and 1.51 (95% CI, 0.81-2.83) at 1 year. Bupropion and placebo groups did not differ in cardiovascular mortality at 1 year (0% vs 2%), in blood pressure at follow-up, or in cardiovascular events at end-of-treatment (16% vs 14%, incidence rate ratio [IRR]1.22 (95% CI: 0.64-2.33) or 1 year (26% vs 18%, IRR 1.56, 95% CI 0.91-2.69). Conclusions Bupropion improved short-term but not long-term smoking cessation rates over intensive counseling and appeared to be safe in hospitalized smokers with acute cardiovascular disease.

Objective To understand the psychosocial outcomes related to decision-making processes of individuals eligible for participation in clinical trials. Methods Individuals eligible to participate in selected clinical trials were contacted to complete two surveys; one shortly after participants were identified, and the second 6 weeks after the first survey was completed ( N = 50). Measures included subjective informed consent; satisfaction with decision-making; decisional regret; and timing of consent (early versus late signers). ANOVA and correlation coefficients were used to test the relationships between variables. Results Early signers reported themselves to be less informed about the details of their particular clinical trials than later signers ( M = 81.9 versus 91.2; F = 5.5; p = .02). There was a non-significant trend for early signers to be less satisfied with their decisions than late signers. Satisfaction with decision-making and subjective informed consent were both strongly associated with later decisional regret ( r = −.32 and −.30, respectively). However, there was no relationship between timing of consent and decisional regret. Conclusion Participants who enroll in clinical trials quickly may not believe they fully understand the implications of trial participation. In general, participants who do not believe they fully understand the implications of trial participation, or who are less satisfied with their decision to enroll in the trial may ultimately feel regret about their decision to participate. Practice implications More effort is needed to ensure that clinical trial participants fully understand the risks and benefits of participation and are satisfied with their decision to enroll in a trial prior to signing consent forms.

Determinants of physical activity in minority populations remain under-explored. Acculturation is one proposed mechanism for the disparities that exist between racial and ethnic groups in health outcomes.This cross-sectional study evaluated the relation of language acculturation and generation in the US since migration with leisure-time and occupational activity. A low-income, multiethnic urban population was recruited from Massachusetts small businesses (SB) (n=1,725) and health centers (HC) (n=2,205). Baseline data were collected between May 2000 and February 2002.Individuals with low acculturation reported leisure-time activity 3-5 MET hours/week lower than those who were highly acculturated (P0.05). Generation predicted leisure-time activity only in SB participants. In the HC, least acculturated participants reported occupational activity 10-12 MET hours/week higher than highly acculturated participants. In SB men, acculturation was inversely associated with occupational activity; in SB women, language acculturation was positively associated with occupational activity. Generation was not predictive of occupational activity.Language acculturation and generation were positively associated with leisure-time activity. Language acculturation is also associated with occupational activity. Acculturation is important to consider when designing public health interventions.

Marriage is a ubiquitous social status that consistently is linked to health. Despite this, there has been very little theory development or related research on the extent to which couple members are jointly motivated to and actively engage in health-enhancing behaviors. In this paper we propose an integrative model, based on interdependence theory and communal coping perspectives, that explicitly considers dyadic processes as determinants of couple behavior. Our integrated model applies these constructs to consider how couple dynamics might influence adoption of risk-reducing health habits. Accordingly, we suggest that the couple's interdependence can transform motivation from doing what is in the best interest of the self (person-centered), to doing even selfless actions that are best for the continuation of the relationship (relationship-centered). In turn, this transformation can lead to enhanced motivation for the couple to cope communally or act cooperatively in adopting health-enhancing behavior change. Implications for research related to couples and health behavior change are also highlighted.

Immigrants to the US are not only an increasingly significant demographic group but overall they also have lower socioeconomic status (SES) than the native-born. It is known that tobacco use is a major health risk for groups that have low SES. However, there is some evidence that tobacco use among certain immigrant groups is lower than among the respective native-born ethnic group, and that immigrant assimilation is positively related to tobacco use. We investigated the relationship between immigrant generation and daily smoking, using the Tobacco Use Supplement of the Current Population Survey (TUS-CPS), 1995-96, a national data set representative of the US general and immigrant populations. Our multivariate logistic regression analysis of the relationship between immigrant generation and daily smoker status (n = 221,798) showed that after controlling for age, gender, race/ethnicity, SES variables (i.e. equivalized household income, education, occupation), and central-city residence, the odds of being a daily smoker were highest among US-born individuals of US-born parents (reference group) and lowest among foreign-born individuals (95% CI: 0.54-0.62). Being a second-generation immigrant (i.e. US born) with two immigrant parents also conferred a protective effective from smoking (95% CI: 0.64-0.77). However, having only one foreign-born parent was not protective against smoking. Testing for interaction effects, we also found that being foreign born and being second generation with two immigrant parents were especially protective against smoking among females (vis-à-vis males); racial/ethnic minorities (vis-à-vis whites); and low-income individuals (vis-à-vis high-income individuals). We discuss possible mechanisms that may explain the protective effect against smoking of being foreign born and being second generation with two immigrant parents, including differences in the stage of the tobacco epidemic between immigrants' countries of origin and the US, the "healthy immigrant effect", and anti-smoking socialization in immigrant families.

Background This article proposes a conceptual framework for addressing social contextual factors in cancer prevention interventions, and describes work that operationalizes this model in interventions for working class, multiethnic populations. Methods The Harvard Cancer Prevention Program Project includes three studies: (1) an intervention study in 25 small businesses; (2) an intervention study in 10 health centers; and (3) a computer simulation modeling project that translates risk factor modifications into gains in life expectancy and number of cancers averted. The conceptual framework guiding this work articulates pathways by which social context may influence health behaviors, and is used to frame the interventions and guide evaluation design. Results Social contextual factors cut across multiple levels of influence, and include individual factors (e.g., material circumstances, psychosocial factors), interpersonal factors (e.g., social ties, roles/responsibilities, social norms), organizational factors (e.g., work organization, access to health care), and neighborhood/community factors (e.g., safety, access to grocery stores). Social context is shaped by sociodemographic characteristics (e.g., social class, race/ethnicity, gender, age, language) that impact day-to-day realities. Conclusions By illuminating the pathways by which social contextual factors influence health behaviors, it will be possible to enhance the effectiveness of interventions aimed at reducing social inequalities in risk behaviors.

The Transtheoretical Model (TTM) has been extensively validated in representative samples of adult smokers. Stage effects, i.e., the patterned relationships between Stage of Change (SOC) and other TTM variables, have been reported in a variety of samples. This study describes reliability data for the TTM variables and tests the stage effects with an ethnically diverse sample of 296 parents with young children. On the basis of theory and previous empirical evidence from a general population, it is possible to make quantitative predications about the magnitude of the expected effect sizes for the Decisional Balance, Situational Temptations, and Processes of Change subscales. For each variable, both a test of significance and a comparison with the expected effect sizes is reported. Results indicated significant stage differences for 8 of the 11 TTM subscales, and all quantitative predictions were confirmed. This study supports the use of TTM measures in an ethnically diverse sample.

Background: Despite advances in smoking treatment, cessation rates remain stagnant, possibly a function of the lack of new channels to reach heavily addicted smokers. This cross-sectional study examined home care nurses’ attitudes, beliefs, and counseling behaviors regarding counseling their home care patients who smoke. Methods: Home healthcare nurses (N=98) from the Visiting Nurse Association of Rhode Island were randomly selected to participate in a study helping home-bound medically ill smokers to quit. At baseline, nurses completed a questionnaire that assessed a constellation of cognitive factors (self-efficacy, outcome expectations, perceived effectiveness, risk perception, motivation, and perceived patient adherence) as correlates of self-reported nurse counseling behaviors. Results: Nurses with higher outcome expectations spent more time counseling their patients about quitting ( p p p n =13) provided follow-up to their patients. Nurses who reported higher levels of both risk perception (regarding the harmful effects of smoking) and perceived effectiveness were more likely to recommend the nicotine patch. Conclusions: Attitudes and beliefs about smoking are significantly associated with nurse counseling behaviors. Helping nurses to overcome their barriers to smoking counseling may open up new channels for smoking intervention.

Background . We report process data on the feasibility of delivering a clinical preventive nutrition intervention that was effective in increasing participants' consumption of fruits and vegetables. We also examine relationships between process variables and study outcomes. Methods . We randomly assigned six practice sites in a managed care organization to a dietary intervention or control condition. We invited adults 18 years of age or older scheduled for routine health visits within the subsequent 2 months to participate. Of the 566 patients we contacted from the intervention sites, 230 (41%) enrolled. From the control sites, we contacted 617, and 274 (44%) enrolled. Intervention participants received a tailored letter providing feedback on their consumption of target foods together with recommendations for improvement, stage-matched nutrition education booklets, a diet-health endorsement from their primary care providers (PCPs), and two motivational counseling telephone calls. Of enrollees, 195 (85%) in the intervention group and 252 (92%) in the control group returned the final survey 3 months later. Results . Seventy-one percent of both participants and PCPs reported that the PCPs had discussed the relationship between diet and health at their visit. Fifty-seven percent of participants and 62% of PCPs reported that they discussed the complete diet-health endorsement, which included: (1) acknowledgment of the relationship between diet and health and (2) tailored study recommendations. The inclusion of both parts of the diet-health endorsement, but not the length of time spent, appeared to correlate with healthful outcomes. Conclusions . These process data suggest that the brief PCP diet-health endorsement contributed to the intervention effect on fruits and vegetables.

Background . We evaluated a multifaceted preventive nutrition intervention to improve dietary habits among adult primary care patients. Methods . We randomized six group practices in a managed care organization. Participants completed baseline and 3-month follow-up surveys. The intervention comprised (1) mailed personalized dietary recommendations and educational booklets focusing on fruits and vegetables, red meat, and dairy foods, tailored to patients' baseline intake and stage of readiness to change eating behaviors; (2) verbal endorsement by the primary care provider of the benefits of these recommendations; and (3) two motivational counseling sessions with telephone counselors to set dietary goals. Results . Among the 230 subjects in the intervention group and 274 in the control group, mean age was 54 years, 70% were female, and 91% were white and 7% African American. Eighty-nine percent of the participants completed the follow-up survey. We measured change in intake of foods using results from the baseline and follow-up food frequency questionnaires. Using an intention-to-treat analysis and adjusting for age, sex, race, and baseline intake, the change in fruit and vegetable intake in the intervention group was 0.6 (95% confidence interval 0.3, 0.8) servings/day higher than in the control group. There was no intervention effect on red meat and dairy products. Conclusions . Tailored clinical nutrition interventions that combine brief physician endorsement with practice supports may be effective in changing patients' eating behavior.

Background. Children's exposure to environmental tobacco smoke (ETS) is unacceptably high; almost 40% of children in the United States are regularly exposed to ETS. Methods. This paper presents a review of the literature that evaluates interventions designed to reduce ETS exposure among young children. In addition, it presents the study design for Project KISS (Keeping Infants Safe from Smoke), an intervention designed to utilize exposure-related feedback to increase parents' motivation for ETS reduction and to reduce household ETS levels. Baseline data are presented to illustrate factors that should be addressed in ETS interventions. Results. The literature review demonstrates the dearth of studies in the literature targeting ETS reduction among children. Participants in Project KISS believed that smoking had affected their children's health and were in later stages of motivational readiness to quit smoking than is typically observed. However, they face a number of challenges to smoking , such as high prevalence of nicotine dependence , high prevalence of living with other smokers, and socioeconomic and stress-related barriers. Conclusions. The policy implications of this research are discussed, and recommendations are made for future research.

Motivational interviewing (MI) has been well studied in specialist settings. There has been considerable interest in applying MI to community health care settings. Such settings represent a significant departure from the more traditional, specialist settings in which MI has been developed and tested. The purpose of this paper is to provide a brief overview of MI and to identify and discuss the key issues that are likely to arise when adapting this approach to health care and public health settings. This paper provides an overview of important issues to consider in adapting an effective counseling strategy to new settings, and is intended to begin a dialogue about the use of MI in community health care settings.

This paper reports a pilot test of the feasibility of implementing an extension of the Expanded Food and Nutrition Education Program (EFNEP) home-based nutrition education intervention in order to maximize involvement of participants’ naturally occurring social networks and to target cancer prevention eating patterns. Community residents served as hostesses of a two-session “Nutrition Home Party” and invited at least six family members/friends to attend the sessions, which were held in their homes. Paraprofessionals indigenous to the community facilitated the sessions. Nutrition education sessions were based on the Food Guide Pyramid and the Nutrition Facts label, with emphasis placed on encouraging participants to consume at least five servings of fruits and vegetables a day to reduce their risk of cancer. Preliminary experience with a home-based intervention model indicates that there is considerable potential for working through existing social networks to reach low-income populations.

Objectives . The purpose of this paper is to examine the characteristics of smokers who adhere to a hospital smoking ban, compared to those who do not. Design . The data presented in this paper are baseline and discharge survey data collected among hospitalized smokers. Setting . This study was conducted in two teaching hospitals in a northeastern city. Patients/participants . The subjects were 358 smokers who participated in a larger smoking intervention trial. Main results . Seventy-six percent of the subjects reported adhering to the smoke-free policy during their hospital stay. In a multivariate model, demographic factors that predicted adherence included being older, having shorter length of stay, not reporting recreational drug use in the previous 12 months, and not having alcohol-related problems. Smoking history variables that predicted adherence included having had at least 24 h of abstinence in the 7 days prior to hospitalization; self-efficacy variables (e.g., confidence in ability to quit smoking in 1 month and less anticipated difficulty refraining from smoking during hospitalization) also predicted adherence. Conclusions . Understanding the factors that predict adherence to health care policies can provide useful information for health promotion interventions in a medical setting. The implications of these findings are discussed.

Background. Gender differences in smoking and smoking cessation among participants in the Working Well Trial are characterized. Methods. A prospective randomized matched-pair evaluation was conducted among 90 predominantly blue-collar worksites. Cross-sectional surveys of employees' tobacco use behaviors were conducted at baseline and after a 2.5-year smoking cessation intervention. Respondents included 5,523 females and 12,313 males at baseline and 4,663 females and 10,919 males at follow-up. The main outcome measures included self-reported continuous smoking abstinence rates for 7 days and for 6 months. Results. Smoking prevalence was significantly higher for women than for men at baseline, but not at follow-up. Variables believed to influence smoking cessation were compared at baseline. Significant gender differences were found for number of cigarettes smoked/day, number of previous quit attempts, job strain, stage of change, and behavioral processes of change. At follow-up, no gender differences in quit rates were observed; however, women in the intervention condition were more likely to quit than women in the control condition, whereas no differences were seen among men by treatment condition. Conclusions. Gender is not a strong predictor of smoking cessation in this population; however, women were more likely to quit with an intervention than without one.

T he workplace is an effective channel for disseminating health promotion interventions,’ and it is becoming an increasingly important vehicle for reaching women. In the United States, 54% of women over 18 work outside the home. Bureau of Labor projections indicate that by the year 2005, women will be entering the workforce at a faster rate than men. Manufacturing worksites, in particular, offer an effective means of reaching women who are underserved, undereducated, and from lower income strata. The worksite may play a particularly important role in reaching these underserved women because they may have less access to traditional channels for health care and prevention. However, poor participation in worksite programs is often cited as a major contributor to less than optimal outcomes in worksite-based programs. Little is known about the determinants of participation in worksite health promotion programs. In addition, there is no common definition of “participation,” which adds to the confusion in this literature.2 While it is difficult to make comparisons across data that use different definitions of participation, several recurrent themes exist. Demographic characteristics tend to predict participation in worksite health promotion programs. Younger employees, those with higher education levels, and women are more likely to participate,‘-(j although men are more likely to participate in fitness programs.7,8 Organizational or worksite-level factors that promote individual participation in health promotion programs are less clear. Top management support, willingness to allow attendance on company time, and line supervisor permission to attend programs all seem to play a role in facilitating participation. Although the importance of organizational factors has been acknowledged,2,6,9-” the systematic study of how these factors differentially predict participation by Q 1996 by The Jacobs Institute of Women’s Health Published by Elsevier Science Inc 1049-3867/96/$15.00 SSDI 1049-3867(95)00049-6

Objectives. A key variable for the design of individual and public health interventions for smoking cessation is Stage of Change, a variable which employs past behavior and behavioral intention to characterize an individual′s readiness to change. Reactively recruited samples distort estimates of the stage distribution in the population because such samples attract a disproportionate number of late-stage participants. Three representative samples are described which provide accurate estimates of the stage distribution in the population. These samples are of adequate size to permit within-sample comparisons with respect to sex, age, Hispanic or non-Hispanic origin, race, and education level. The implications of using stage distribution as a tool for planning intervention is discussed. Method. The first sample of 4,144 smokers was from the state of Rhode Island and involved a random-digit-dial survey. The second sample of 9,534 smokers was from the state of California and involved a stratified random-digit-dial survey. The third sample of 4,785 smokers was from a total of 114 worksites located in four different geographic locations. Results. The stage distributions were approximately identical across the three samples, with approximately 40% of the sample in Precontemplation, 40% in Contemplation, and 20% in Preparation. The stage distribution was generally stable across age groups with the exception of the 65 years and older group. Education level did affect the stage distribution with the proportion of the sample in Precontemplation decreasing as education level increased. In all three samples, minor differences in stage distribution were related to Hispanic origin and race, but the pattern was not consistent across the samples. Conclusions. The pattern of stage distribution has important implications for the design of interventions. Existing interventions are most appropriate for the Preparation stage, but the majority of the three samples were in the first two stages, resulting in a likely mismatch between the smoker and the intervention. The stability of distribution across age suggests that interventions that are appropriately matched to stage can be applied across all age groups. The differences found with respect to education, Hispanic origin, and race can serve as a guide to the tailoring of intervention materials.

Background . The Working Well Trial, the largest randomized worksite health promotion trial to date, tests the effects of cancer prevention and control interventions on dietary and smoking behaviors of employees and the worksite environment. The trial is a 5-year cooperative agreement conducted in 57 matched pairs of worksites in 16 states by four study centers, a coordinating center, and the National Cancer Institute. The dual aims of this paper are to: (a) present a baseline description of the dietary and smoking habits of 20,801 employees, who are predominantly blue-collar workers; and (b) describe the social and physical environments of their worksites that may facilitate or hinder health behavior changes. Methods . The self-administered baseline survey of individuals consisted of a core set of questions common across all study centers on diet and smoking. The organizational survey consisted to eight instruments administered via interviews with key informants in each worksite. Continuous variables were analyzed by a mixed linear model and binary data were analyzed by the Generalized Estimating Equation. Results . The population represented is largely male (67.5%) and blue collar (53.5%). Mean levels of fat and fiber intakes were close to the national averages (36.6% of calories as fat and 13.1 g of fiber). Smoking prevalence (25.2%) was slightly lower than the national average. The worksites had a high level of health promotion activites (42% had nutrition programs, 53% had smoking control programs), but lacked environmental support for dietary behavior change and perceived support for smoking cessation. Conclusions . These findings replicate and extend previous research results to a large sample of diverse, largely blue-collar worksites. In addition the baseline results lay a foundation for the development of new insight into the relationship between individual and organizational level variables that may interact to influence behavioral and cultural norms.

Background. Individuals who have multiple poor health behaviors account for a disproportionately large percentage of the preventable U.S. health care cost burden. Understanding the relationships between multiple risk factors is important for the design of both individual and public health interventions. There have been few efforts to examine the cooccurrence of psychosocial and motivational mechanisms that mediate smoking, dietary fat intake, and physical activity in a defined population of blue collar workers. Methods. The sample comprised 1,559 manufacturing workers who participated in a self-help physical activity intervention and who completed a computerized assessment battery about their smoking, dietary fat intake, physical activity, and demographic characteristics. Results. Twenty-six percent of the sample were smokers, 51% did not exercise regularly, and 35% consumed more than an estimated 40% of calories per day from fat. Almost half of the sample was in the later stages of readiness for physical activity and dietary fat intake, compared with only 3% for smoking. Only 12% of the smokers had smoking as their only risk factor. Smokers were significantly more likely to engage in poor dietary and physical activity behaviors, compared with nonsmokers. The relationship among smoking status and the other risk factors was apparent both in terms of dietary fat and physical activity behaviors, as well as mediators such as motivation for change. Lower dietary fat intake was associated with an absence of the other two risk factors. Conclusions. The results suggest that there are important mediating mechanisms both within and among workers with one or more risk factors. Smokers are a particularly important target for health promotion interventions, and it may be possible to make initial contact with them through other health programs at the worksite. The role of other lifestyle changes as a gateway to smoking cessation has not yet been explored, but may have potential for reaching smokers who are very low in their motivational readiness to change. The implications of these findings for research and the design of multiple risk factor interventions are discussed.

To evaluate the relationship between self-reported exposure to environmental tobacco smoke and saliva cotinine concentrations, we studied 186 nonsmokers. Each participant completed an exposure questionnaire, kept a daily exposure diary for 7 days, and provided a saliva sample for cotinine analysis. Salivary cotinine concentrations were measured using gas chromatography/mass spectrometry. Of the volunteers, 30% lived with one or more smokers, and 84% were regularly exposed to smokers at work. Eighty-three percent of the volunteers had detectable saliva cotinine concentrations (≥0.5 ng/ml) (median = 1.1; range = 0.5-7.4 ng/ml). Cotinine concentrations were related to exposure in the household and at the workplace. Volunteers who lived with smokers had significantly higher cotinine levels (median = 1.0; range =

Background . Medical illness has often been thought to provide smokers with motivation to quit smoking. However, the actual impact that illness and hospitalization has on smokers' interest in cessation is not clear. Further, little is known about the role that hospital staff play in encouraging cessation. Methods . This article is a descriptive study examining smoking prevalence and interest in cessation among 304 inpatients hospitalized in a specialized cardiovascular disease unit and a general medical unit. In addition, the efforts of hospital staff in promoting cessation were assessed. Results . The overall smoking prevalence among this older sample was 16%. Although the majority of smokers (79%) indicated a desire to quit smoking, there was little interest in using formal treatment options to quit. Quitting on one's own was the most preferred cessation strategy. Approximately one-third of the smokers expressed interest in receiving cessation counseling from their physicians. Patient reports indicated that both physicians and nurses on the general medical unit intervened on smoking less frequently than staff on the cardiovascular disease unit. Seventy-one percent of all smokers reported that the medical resident did not discuss smoking with them. Conclusion . Despite the small number of smokers in this sample, this study has implications for development of training programs for hospital staff on delivery of brief smoking interventions.

Cigarette smoking is an intractable public health problem and thesingle largest risk factor for a variety of malignancies, includinglung cancer. Worldwide, about 3 million people die each year ofsmoking-related disease, and this is expected to increase to > 10million deaths per year. The Agency for Health Care Policy and Researchhas published a clinical practice guideline detailing available outcomedata for various smoking cessation strategies. In particular, it hasbeen recommended that all patients be screened for smoking status onevery health-care visit, and that all patients who smoke be stronglyadvised to quit and offered assistance to do so. Health-care providersplay a vital role in the effort to reduce the prevalence of smoking bydelivering smoking cessation advice, supporting community-based effortsto control tobacco, and becoming involved in the tobacco controldebate.