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Introduction: Although technology-assisted tobacco interventions (TATIs) are effective, they are underused due to recruitment challenges. We tested whether we could successfully recruit smokers to a TATI using peer marketing through a social network (Facebook)., Methods: We recruited smokers on Facebook using online advertisements. These recruited smokers (seeds) and subsequent waves of smokers (peer recruits) were provided the Share2Quit peer recruitment Facebook app and other tools. Smokers were incentivized for up to seven successful peer recruitments and had 30 days to recruit from date of registration. Successful peer recruitment was defined as a peer recruited smoker completing the registration on the TATI following a referral. Our primary questions were (1) whether smokers would recruit other smokers and (2) whether peer recruitment would extend the reach of the intervention to harder-to-reach groups, including those not ready to quit and minority smokers., Results: Overall, 759 smokers were recruited (seeds: 190; peer recruits: 569). Fifteen percent (n = 117) of smokers successfully recruited their peers (seeds: 24.7%; peer recruits: 7.7%) leading to four recruitment waves. Compared to seeds, peer recruits were less likely to be ready to quit (peer recruits 74.2% vs. seeds 95.1%), more likely to be male (67.1% vs. 32.9%), and more likely to be African American (23.8% vs. 10.8%) (p < .01 for all comparisons)., Conclusions: Peer marketing quadrupled our engaged smokers and enriched the sample with not-ready-to-quit and African American smokers. Peer recruitment is promising, and our study uncovered several important challenges for future research., Implications: This study demonstrates the successful recruitment of smokers to a TATI using a Facebook-based peer marketing strategy. Smokers on Facebook were willing and able to recruit other smokers to a TATI, yielding a large and diverse population of smokers., (© The Author 2016. Published by Oxford University Press on behalf of the Society for Research on Nicotine and Tobacco. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Effective web-assisted tobacco interventions (WATIs) have been underutilized by smokers; moreover, despite practice guideline recommendations, clinical teams do not routinely refer smokers to WATIs. Our goal was to test a clinical practice innovation, an ePortal designed to change practice and patient behavior. Our hypotheses were that the integrated system would result in increased smoker referrals, with an automated follow-up system resulting in more smoker registrations and finally augmentations of the WATI would result in more smokers quitting at 6 months., Methods: Practice ePortal Implementation Trial: Practices (n = 174) were randomized to an online practice ePortal with an "e-referral tool" to the WATI (e-referred smokers received automated email reminders from the practice) and with practice feedback reports with patient tracking and practice-to-patient secure messaging versus comparison (a paper "referral prescription"). Implementation success was measured by the number of smokers referred and smokers registering. Clinical Effectiveness Trial: To estimate the effectiveness of the WATI components on 6-month smoking cessation, registered smokers were randomized into three groups: a state-of-the-art tailored WATI control [control], the WATI enhanced with proactive, pushed tailored email motivational messaging (messaging), and the WATI with messaging further enhanced with personal secure messaging with a tobacco treatment specialist and an online support group (personalized)., Results: Practice ePortal Trial results: A total of 4789 smokers were referred. The mean smokers referred per practice was not statistically different by group (ePortal 24.89 (SD 22.29) versus comparison 30.15 (SD 25.45), p = 0.15). The e-referral portal implementation program resulted in nearly triple the rate of smoker registration (31 % of all smokers referred registered online) versus comparison (11 %, p < 0.001). Clinical Effectiveness Trial results: Active smokers randomized to the personalized group had a 6-month cessation rate of 25.2 %, compared with the messaging group (26.7 %) and the control (17 %). Next, when using an inverse probability weighted selection model to account for attrition, those randomized to the two groups that received motivational messaging (messaging or personalized) were more likely to quit than those in the control (p = 0.04)., Conclusions: Among all smokers referred, the e-referral resulted in nearly threefold greater registrants (31 %) than paper (11 %). The practice ePortal smokers received multiple reminders (increasing registration opportunities), and the practices could track patient progress. The result was more smokers registering and, thus, more cessation opportunities. Combining the proactive referral and the WATI resulted in higher rates of smoking cessation., Trial Registration: Web-delivered Provider Intervention for Tobacco Control (QUIT-PRIMO) - a randomized controlled trial: NCT00797628 .

Background: African American women are one of the least active demographic groups in the US, with only 36% meeting the national physical activity recommendations in comparison to 46% of White women. Physical activity begins to decline in African American women in adolescence and continues to decline into young adulthood. Yet, few interventions have been developed to promote physical activity in African American women during this critical period of life. The purpose of this article was to evaluate the acceptability and feasibility of a culturally-relevant Internet-enhanced physical activity pilot intervention for overweight/obese African American college females and to examine psychosocial and behavioral characteristics associated with intervention adherence and completion., Methods: A 6-month single group pre-posttest design was used. Participants (n = 27) accessed a culturally-relevant Social Cognitive Theory-based physical activity promotion website while engaging in a minimum of four moderate-intensity physical activity sessions each week. Acceptability and feasibility of the intervention was assessed by participant retention and a consumer satisfaction survey completed by participants., Results: Fifty-six percent of participants (n = 15) completed the intervention. Study completers were more physically active at baseline (P = 0.05) and had greater social support for exercise from family members (P = 0.04). Sixty percent of study completers (n = 9) reported the website as "enjoyable" or "very enjoyable" to use and 60% (n = 9) reported increased motivation from participation in the physical activity program. Moreover, 87% (n = 13) reported they would recommend the website to a friend., Conclusions: Results provide some preliminary support for the acceptability and feasibility of an Internet-enhanced physical activity program for overweight/obese African American women, while highlighting important limitations of the approach. Successful promotion of physical activity in college aged African American women as they emerge into adulthood may result in the development of life-long healthy physical activity patterns which may ultimately reduce physical activity-related health disparities in this high risk underserved population. Future studies with larger samples are needed to further explore the use of Internet-based programs to promote physical activity in this population.

We examined pregnant women's interest in using a website or mobile application to help them gain a healthy amount of weight during pregnancy. Pregnant women (N = 64) completed a short questionnaire during routine prenatal care at hospital-based obstetric clinics in central Massachusetts during April-August 2012. Eighty-six percent reported interest in using a website or mobile application to help them gain a healthy amount of weight; interest ranged from 67% to 100% across demographics, clinical characteristics, and technology use. The Internet is a promising modality for delivering interventions to prevent excessive gestational weight gain and associated maternal and child health consequences., (Copyright © 2014 Elsevier B.V. All rights reserved.)

Introduction: Innovative approaches are needed to promote physical activity among young adult overweight and obese African American women. We sought to describe key elements that African American women desire in a culturally relevant Internet-based tool to promote physical activity among overweight and obese young adult African American women., Methods: A mixed-method approach combining nominal group technique and traditional focus groups was used to elicit recommendations for the development of an Internet-based physical activity promotion tool. Participants, ages 19 to 30 years, were enrolled in a major university. Nominal group technique sessions were conducted to identify themes viewed as key features for inclusion in a culturally relevant Internet-based tool. Confirmatory focus groups were conducted to verify and elicit more in-depth information on the themes., Results: Twenty-nine women participated in nominal group (n = 13) and traditional focus group sessions (n = 16). Features that emerged to be included in a culturally relevant Internet-based physical activity promotion tool were personalized website pages, diverse body images on websites and in videos, motivational stories about physical activity and women similar to themselves in size and body shape, tips on hair care maintenance during physical activity, and online social support through social media (eg, Facebook, Twitter)., Conclusion: Incorporating existing social media tools and motivational stories from young adult African American women in Internet-based tools may increase the feasibility, acceptability, and success of Internet-based physical activity programs in this high-risk, understudied population.

Background: Tailored, web-assisted interventions can reach many smokers. Content from other smokers (peers) through crowdsourcing could enhance relevance., Purpose: To evaluate whether peers can generate tailored messages encouraging other smokers to use a web-assisted tobacco intervention (Decide2Quit.org)., Methods: Phase 1: In 2009, smokers wrote messages in response to scenarios for peer advice. These smoker-to-smoker (S2S) messages were coded to identify themes. Phase 2: resulting S2S messages, and comparison expert messages, were then e-mailed to newly registered smokers. In 2012, subsequent Decide2Quit.org visits following S2S or expert-written e-mails were compared., Results: Phase 1: a total of 39 smokers produced 2886 messages (message themes: attitudes and expectations, improvements in quality of life, seeking help, and behavioral strategies). For not-ready-to-quit scenarios, S2S messages focused more on expectations around a quit attempt and how quitting would change an individual's quality of life. In contrast, for ready-to-quit scenarios, S2S messages focused on behavioral strategies for quitting. Phase 2: In multivariable analysis, S2S messages were more likely to generate a return visit (OR=2.03, 95% CI=1.74, 2.35), compared to expert messages. A significant effect modification of this association was found, by time-from-registration and message codes (both interaction terms p<0.01). In stratified analyses, S2S codes that were related more to "social" and "real-life" aspects of smoking were driving the main association of S2S and increased return visits., Conclusions: S2S peer messages that increased longitudinal engagement in a web-assisted tobacco intervention were successfully collected and delivered. S2S messages expanded beyond the biomedical model to enhance relevance of messages., Trial Registration: This study is registered at www.clinicaltrials.gov NCT00797628 (web-delivered provider intervention for tobacco control [QUIT-PRIMO]) and NCT01108432 (DPBRN Hygienists Internet Quality Improvement in Tobacco Cessation [HiQuit])., (© 2013 American Journal of Preventive Medicine. All rights reserved.)

Introduction: Smoking is the most preventable cause of death. Although effective, Web-assisted tobacco interventions are underutilized and recruitment is challenging. Understanding who participates in Web-assisted tobacco interventions may help in improving recruitment., Objectives: To understand characteristics of smokers participating in a Web-assisted tobacco intervention (Decide2Quit.org)., Methods: In addition to the typical Google advertisements, we expanded Decide2Quit.org recruitment to include referrals from medical and dental providers. We assessed how the expanded recruitment of smokers changed the users' characteristics, including comparison with a population-based sample of smokers from the national Behavioral Risk Factors Surveillance Survey (BRFSS). Using a negative binomial regression, we compared demographic and smoking characteristics by recruitment source, in particular readiness to quit and association with subsequent Decide2Quit.org use., Results: The Decide2Quit.org cohort included 605 smokers; the 2010 BRFSS dataset included 69,992. Compared to BRFSS smokers, a higher proportion of Decide2Quit.org smokers were female (65.2% vs 45.7%, P=.001), over age 35 (80.8% vs 67.0%, P=.001), and had some college or were college graduates (65.7% vs 45.9%, P=.001). Demographic and smoking characteristics varied by recruitment; for example, a lower proportion of medical- (22.1%) and dental-referred (18.9%) smokers had set a quit date or had already quit than Google smokers (40.1%, P<.001). Medical- and dental-referred smokers were less likely to use Decide2Quit.org functions; in adjusted analysis, Google smokers (predicted count 17.04, 95% CI 14.97-19.11) had higher predicted counts of Web page visits than medical-referred (predicted count 12.73, 95% CI 11.42-14.04) and dental-referred (predicted count 11.97, 95% CI 10.13-13.82) smokers, and were more likely to contact tobacco treatment specialists., Conclusions: Recruitment from clinical practices complimented Google recruitment attracting smokers less motivated to quit and less experienced with Web-assisted tobacco interventions.

Background: Previous studies examining characteristics of Internet health information seekers do not distinguish between those who only seek for themselves, and surrogate seekers who look for health information for family or friends. Identifying the unique characteristics of surrogate seekers would help in developing Internet interventions that better support these information seekers., Objective: To assess differences between self seekers versus those that act also as surrogate seekers., Methods: We analyzed data from the cross-sectional Pew Internet and American Life Project November/December 2008 health survey. Our dependent variable was self-report of type of health information seeking (surrogate versus self seeking). Independent variables included demographics, health status, and caregiving. After bivariate comparisons, we then developed multivariable models using logistic regression to assess characteristics associated with surrogate seeking., Results: Out of 1250 respondents who reported seeking health information online, 56% (N=705) reported being surrogate seekers. In multivariable models, compared with those who sought information for themselves only, surrogate seekers were more likely both married and a parent (OR=1.57, CI=1.08, 2.28), having good (OR=2.05, CI=1.34, 3.12) or excellent (OR=2.72, CI=1.70, 4.33) health status, being caregiver of an adult relative (OR=1.76, CI=1.34, 2.30), having someone close with a serious medical condition (OR=1.62, CI=1.21, 2.17) and having someone close to them facing a chronic illness (OR=1.55, CI=1.17, 2.04)., Conclusions: Our findings provide evidence that information needs of surrogate seekers are not being met, specifically of caregivers. Additional research is needed to develop new functions that support surrogate seekers., (Copyright © 2012 Elsevier Ireland Ltd. All rights reserved.)

Background: Brief clinician delivered advice helps in tobacco cessation efforts. This study assessed the impact of our intervention on instances of advice given to dental patients during visits on tobacco use quit rates 6 months after the intervention., Methods: The intervention was cluster randomized trial at the dental practice level. Intervention dental practices were provided a longitudinal technology-assisted intervention, oralcancerprevention.org that included a series of interactive educational cases and motivational email cues to remind dental provides to complete guideline-concordant brief behavioral counseling at the point of care. In all dental practices, exit cards were given to the first 100 consecutive patients, in which tobacco users provided contact information for a six month follow-up telephone survey., Results: A total of 564 tobacco using dental patients completed a six month follow-up survey. Among intervention patients, 55% reported receiving advice to quit tobacco, and 39% of control practice patients reported receiving advice to quit tobacco (p < 0.01). Six-month tobacco use quit rates were not significantly between the Intervention (9%) and Control (13%) groups, (p = 0.088)., Conclusion: Although we increased rates of cessation advice delivered in dental practices, this study shows no evidence that brief advice by dentist's increases long-term abstinence in smokers., Trial Registration: ClinicalTrials.gov NCT00627185.

Resource effect studies can be useful in highlighting areas of improvement in informatics tools. Before a large randomized trial, we tested the functions of the Decide2Quit.org Web-assisted tobacco intervention using smokers (N=204) recruited via Google advertisements. These smokers were given access to Decide2Quit.org for six months and we tracked their usage and assessed their six months cessation using a rigorous follow-up. Multiple, interesting findings were identified: we found the use of tailored emails to dramatically increase participation for a short period. We also found varied effects of the different functions. Functions supporting "seeking social support" (Your Online Community and Family Tools), Healthcare Provider Tools, and the Library had positive effects on quit outcomes. One surprising finding, which needs further investigation, was that writing to our Tobacco Treatment Specialists was negatively associated with quit outcomes.

Introduction: CME providers may be interested in identifying effective marketing strategies to direct users to specific content. Online advertisements for recruiting participants into activities such as clinical trials, public health programs, and continuing medical education (CME) have been effective in some but not all studies. The purpose of this study was to compare the impact of 2 marketing strategies in the context of an online CME cultural competence curriculum (www.c-comp.org)., Methods: In an interrupted time-series quasi-experimental design, 2 marketing strategies were tested: (1) wide dissemination to relevant organizations over a period of approximately 4 months, and (2) Internet paid search using Google Ads (5 consecutive 8-week periods--control 1, cultural/CME advertisement, control 2, hypertension/ content advertisement, control 3). Outcome measures were CME credit requests, Web traffic (visits per day, page views, pages viewed per visit), and cost., Results: Overall, the site was visited 19,156 times and 78,160 pages were viewed. During the wide dissemination phase, the proportion of visits requesting CME credit decreased between the first (5.3%) and second (3.3%) halves of this phase (p = .04). During the Internet paid search phase, the proportion of visits requesting CME credit was highest during the cultural/CME advertisement period (control 1, 1.4%; cultural/CME ad, 4.3%; control 2, 1.5%; hypertension/content ad, 0.6%; control 3, 0.8%; p < .001). All measures of Web traffic changed during the Internet paid search phase (p < .01); however, changes were independent of the advertisement periods. The incremental cost for the cultural advertisement per CME credit requested was US $0.64., Discussion: Internet advertisement focusing on cultural competence and CME was associated with about a threefold increase in requests for CME credit at an incremental cost of under US $1; however, Web traffic changes were independent of the advertisement strategy., (Copyright © 2011 The Alliance for Continuing Medical Education, the Society for Academic Continuing Medical Education, and the Council on CME, Association for Hospital Medical Education.)

Objective: To determine the effectiveness of a provider-based education and implementation intervention for improving diabetes control., Design: Cluster-randomized trial with baseline and follow-up cross sections of diabetes patients in each participating physician's practice., Setting: Eleven US Southeastern states, 2006-08., Participants: Two hundred and five rural primary care physicians., Intervention: Multi-component interactive intervention including Web-based continuing medical education, performance feedback and quality improvement tools. Primary Outcome Measures 'Acceptable control' [hemoglobin A1c ≤9%, blood pressure (BP) <140/90 mmHg, low-density lipoprotein cholesterol (LDL) <130 mg/dl] and 'optimal control' (A1c <7%, BP <130/80 mmHg, LDL <100 mg/dl)., Results: Of 364 physicians attempting to register, 205 were randomized to the intervention (n= 102) or control arms (n= 103). Baseline and follow-up data were provided by 95 physicians (2127 patients). The proportion of patients with A1c ≤9% was similar at baseline and follow-up in both the control [adjusted odds ratio (AOR): 0.94; 95% confidence interval (CI): 0.61, 1.47] and intervention arms [AOR: 1.16 (95% CI: 0.80, 1.69)]; BP <140/90 mmHg and LDL <130 mg/dl were also similar at both measurement points (P= 0.66, P= 0.46; respectively). We observed no significant effect on diabetes control attributable to the intervention for any of the primary outcome measures. Intervention physicians engaged with the Website over a median of 64.7 weeks [interquartile range (IQR): 45.4-81.8) for a median total of 37 min (IQR: 16-66)., Conclusions: A wide-reach, low-intensity, Web-based interactive multi-component intervention did not improve control of glucose, BP or lipids for patients with diabetes of physicians practicing in the rural Southeastern US.

Background: Patient self-management interventions for smoking cessation are effective but underused. Health care providers do not routinely refer smokers to these interventions., Objective: The objective of our study was to uncover barriers and facilitators to the use of an e-referral system that will be evaluated in a community-based randomized trial. The e-referral system will allow providers to refer smokers to an online smoking intervention during routine clinical care., Methods: We devised a four-step development and pilot testing process: (1) system conceptualization using Delphi to identify key functionalities that would overcome barriers in provider referrals for smoking cessation, (2) Web system programming using agile software development and best programming practices with usability refinement using think-aloud testing, (3) implementation planning using the nominal group technique for the effective integration of the system into the workflow of practices, and (4) pilot testing to identify practice recruitment and system-use barriers in real-world settings., Results: Our Delphi process (step 1) conceptualized three key e-referral functions: (1) Refer Your Smokers, allowing providers to e-refer patients at the point of care by entering their emails directly into the system, (2) practice reports, providing feedback regarding referrals and impact of smoking-cessation counseling, and (3) secure messaging, facilitating provider-patient communication. Usability testing (step 2) suggested the system was easy to use, but implementation planning (step 3) suggested several important approaches to encourage use (eg, proactive email cues to encourage practices to participate). Pilot testing (step 4) in 5 practices had limited success, with only 2 patients referred; we uncovered important recruitment and system-use barriers (eg, lack of study champion, training, and motivation, registration difficulties, and forgetting to refer)., Conclusions: Implementing a system to be used in a clinical setting is complex, as several issues can affect system use. In our ongoing large randomized trial, preliminary analysis with the first 50 practices using the system for 3 months demonstrated that our rigorous preimplementation evaluation helped us successfully identify and overcome these barriers before the main trial., Trial: Clinicaltrials.gov NCT00797628; http://clinicaltrials.gov/ct2/show/NCT00797628 (Archived by WebCite at http://www.webcitation.org/61feCfjCy).

Purpose: To investigate the association between physician participants' levels of engagement in a Web-based educational intervention and their patients' baseline diabetes measures., Method: The authors conducted a randomized trial of online CME activities designed to improve diabetes care provided by family, general, and internal medicine physicians in rural areas of 11 southeastern states between September 2006 and July 2008. Using incidence rate ratios derived from negative binomial models, the relationship between physicians' engagement with the study Web site and baseline proportion of their patients having controlled diabetes (hemoglobin A1c < or = 7%) was explored., Results: One hundred thirty-three participants (intervention = 64; control = 69) provided information for 1,637 patients with diabetes. In the intervention group, physicians in practices in the worst quartiles of A1c control were least engaged with the study Web site in nearly all dimensions. Total number of pages viewed decreased as quartile of A1c control worsened (137, 73, 68, 57; P = .007); similarly, for a given 10% increase in proportion of patients with controlled A1c, participants viewed 1.13 times more pages (95% CI: 1.02-1.26, P = .02). In the control group, engagement was neither correlated with A1c control nor different across quartiles of A1c control., Conclusions: Engagement in Web-based interventions is measurable and has important implications for research and education. Because physicians of patients with the greatest need for improvement in A1c control may not use online educational resources as intensely as others, other strategies may be necessary to engage these physicians in professional development activities.

Introduction: Physician use of the Internet for practice improvement has increased dramatically over the last decade, but research shows that many physicians choose not to participate. The current study investigated the association of specific physician characteristics with enrollment rates and intensity of participation in a specific Internet-delivered educational intervention to improve care to post-myocardial infarction (MI) patients., Methods: Primary-care physicians were recruited for participation in a randomized controlled trial designed to compare effectiveness of an intervention Web site versus a control Web site in the management of adult chronic disease. Physicians were informed that the intervention focused on ambulatory post-myocardial infarction patients. Physician characteristics were obtained from a commercial vendor with data merged from the American Medical Association and Alabama State Licensing Board. Enrollment and Web use were tracked electronically., Results: Out of a sample of 1337 eligible physicians, 177 (13.2%) enrolled in the study. Enrollment was higher for physicians with more post-MI patients (> or = 20 vs < 20 patients, 15.3% vs 9.3%, P = .002) and for those practicing in rural compared to urban areas (16.3% vs 12.1%, P = .046). Intensity of use of the Internet courses after initial enrollment was not predicted by physician characteristics in the current sample., Discussion: Physicians with more post-MI patients and rural practice location were found to predict enrollment in an Internet-delivered continuing medical education (CME) intervention designed to improve care for post-MI patients. These factors predicted program interest but not program use. More research is needed to replicate these findings to investigate variables that determine physician engagement in Internet CME.

Links between clinical and public health interventions are limited. Using the Internet as a delivery method provides the potential to link multiple intervention components, but this potential has not yet been realized. In this poster, we present results of a formative assessment to identify approaches to improving clinical-public health linkages.

Background: The dental visit is a unique opportunity for tobacco control. Despite evidence of effectiveness in dental settings, brief provider-delivered cessation advice is underutilized., Objective: To evaluate an Internet-delivered intervention designed to increase implementation of brief provider advice for tobacco cessation in dental practice settings., Methods: Dental practices (N = 190) were randomized to the intervention website or wait-list control. Pre-intervention and after 8 months of follow-up, each practice distributed exit cards (brief patient surveys assessing provider performance, completed immediately after the dental visit) to 100 patients. Based on these exit cards, we assessed: whether patients were asked about tobacco use (ASK) and, among tobacco users, whether they were advised to quit tobacco (ADVISE). All intervention practices with follow-up exit card data were analyzed as randomized regardless of whether they participated in the Internet-delivered intervention., Results: Of the 190 practices randomized, 143 (75%) dental practices provided follow-up data. Intervention practices' mean performance improved post-intervention by 4% on ASK (29% baseline, adjusted odds ratio = 1.29 [95% CI 1.17-1.42]), and by 11% on ADVISE (44% baseline, OR = 1.55 [95% CI 1.28-1.87]). Control practices improved by 3% on ASK (Adj. OR 1.18 [95% CI 1.07-1.29]) and did not significantly improve in ADVISE. A significant group-by-time interaction effect indicated that intervention practices improved more over the study period than control practices for ADVISE (P = 0.042) but not for ASK., Conclusion: This low-intensity, easily disseminated intervention was successful in improving provider performance on advice to quit., Trial Registration: clinicaltrials.gov NCT00627185, http://www.webcitation.org/5c5Kugvzj.

Evaluation of Internet-delivered continuing education for health care providers requires appropriate consideration of their level of participation. To fully assess participation requires multidimensional measures, including factors such as the volume of participation (page views), frequency (visits), variety (components accessed by each provider), and duration (months of activity). We calculated crude and refined (adjusted for study design) measures and then compared these measures across three longitudinal Internet-delivered continuing education to health care providers (N=429). We found that participation varied across study, varied by factor and varied by specific measure. Correlation between crude and refined measures within a factor and across factors differed significantly. Participation assessment of internet-delivered interventions varies by the selection of measure and factor. Further research assessing the potential for these measures to predict intervention effectiveness is needed.

Background: The availability of Internet-based continuing medical education is rapidly increasing, but little is known about recruitment of physicians to these interventions., Objective: The purpose of this study was to examine predictors of physician participation in an Internet intervention designed to increase screening of young women at risk for chlamydiosis., Methods: Eligibility was based on administrative claims data, and eligible physicians received recruitment letters via fax and/or courier. Recruited offices had at least one physician who agreed to participate in the study by providing an email address. After one physician from an office was recruited, intensive recruitment of that office ceased. Email messages reminded individual physicians to participate by logging on to the Internet site., Results: Of the eligible offices, 325 (33.2%) were recruited, from which 207 physicians (52.8%) participated. Recruited versus nonrecruited offices had more eligible patients (mean number of eligible patients per office: 44.1 vs 33.6; P < .001), more eligible physicians (mean number of eligible physicians per office: 6.2 vs 4.1; P < .001), and fewer doctors of osteopathy (mean percent of eligible physicians per office who were doctors of osteopathy: 20.5% vs 26.4%; P = .02). Multivariable analysis revealed that the odds of recruiting at least one physician from an office were greater if the office had more eligible patients and more eligible physicians. More participating versus nonparticipating physicians were female (mean percent of female recruited physicians: 39.1% vs 27.0%; P = .01); fewer participating physicians were doctors of osteopathy (mean percent of recruited physicians who were doctors of osteopathy: 15.5% vs 23.9%; P = .04) or international medical graduates (mean percent of recruited physicians who were international graduates: 12.3% vs 23.8%; P = .003). Multivariable analysis revealed that the odds of a physician participating were greater if the physician was older than 55 years (OR = 2.31; 95% CI = 1.09-4.93) and was from an office with a higher Chlamydia screening rate in the upper tertile (OR = 2.26; 95% CI = 1.23-4.16)., Conclusions: Physician participation in an Internet continuing medical education intervention varied significantly by physician and office characteristics.

Background: Low Chlamydia trachomatis screening rates create an opportunity to test innovative continuing medical education (CME) programs. Few studies of Internet-based physician learning have been evaluated with objective data on practice patterns., Design: This randomized controlled trial tested a multicomponent Internet CME (mCME) intervention for increasing chlamydia screening of at-risk women aged 16 to 26 years., Setting: Eligible physician offices had > or =20 patients at risk for chlamydia as defined by the Health Plan Employer Data and Information Set (HEDIS), had at least one primary care physician (internal medicine, family medicine/general practice, pediatrics) with Internet access, and participated in the study managed care organization. The 191 randomized primary care offices represented 20 states., Intervention: The intervention, available from February to December 2001, consisted of four case-based learning modules, was tailored in real time to each physician based on theory of behavior change, and included office-level feedback of chlamydia screening rates., Main Outcome Measure: HEDIS chlamydia screening rates for the pre-intervention (2000) and post-intervention (2002) periods., Results: Pre-intervention screening rates for the intervention and comparison offices were 18.9% and 16.2% (p =0.135). Post-intervention screening rates for the intervention and comparison offices were 15.5% and 12.4%, respectively (p =0.044, adjusting for baseline performance)., Conclusions: The substantial decline in chlamydia screening rates observed in the comparison offices was significantly attenuated for the intervention offices. The mCME favorably influenced chlamydia screening by primary care physicians.

Background: Engaging practicing physicians in educational strategies that reinforce guideline adoption and improve the quality of healthcare may be difficult. Push technologies such as email offer new opportunities to engage physicians in online educational reinforcing strategies. The objectives are to investigate 1) the effectiveness of email announcements in engaging recruited community-based primary care physicians in an online guideline reinforcement strategy designed to promote Chlamydia screening, 2) the characteristics of physicians who respond to email announcements, as well as 3) how quickly and when they respond to email announcements., Methods: Over a 45-week period, 445 recruited physicians received up to 33 email contacts announcing and reminding them of an online women's health guideline reinforcing CME activity. Participation was defined as physician log-on at least once to the website. Data were analyzed to determine participation, to compare characteristics of participants with recruited physicians who did not participate, and to determine at what point and when participants logged on., Results: Of 445 recruited physicians with accurate email addresses, 47.2% logged on and completed at least one module. There were no significant differences by age, race, or specialty between participants and non-participants. Female physicians, US medical graduates and MDs had higher participation rates than male physicians, international medical graduates and DOs. Physicians with higher baseline screening rates were significantly more likely to log on to the course. The first 10 emails were the most effective in engaging community-based physicians to complete the intervention. Physicians were more likely to log on in the afternoon and evening and on Monday or Thursday., Conclusions: Email course reminders may enhance recruitment of physicians to interventions designed to reinforce guideline adoption; physicians' response to email reminders may vary by gender, degree, and country of medical training. Repetition of email communications contributes to physician online participation.

Background: The World Wide Web has led to the rapid growth of medical information and continuing medical educational offerings. Ease of access and availability at any time are advantages of the World Wide Web. Existing physician-education sites have often been designed and developed without systematic application of evidence and cognitive-educational theories; little rigorous evaluation has been conducted to determine which design factors are most effective in facilitating improvements in physician performance and patient-health outcomes that might occur as a result of physician participation in Web-based education. Theory and evidence-based Web design principles include the use of: needs assessment, multimodal strategies, interactivity, clinical cases, tailoring, credible evidence-based content, audit and feedback, and patient-education materials. Ease of use and design to support the lowest common technology denominator are also important., Objective: Using these principles, design and develop a Web site including multimodal strategies for improving chlamydial-screening rates among primary care physicians., Methods: We used office-practice data in needs assessment and as an audit/feedback tool. In the intervention introduced in 4 phases over 11 months, we provided a series of interactive, tailored, case vignettes with feedback on peer answers. We included a quality-improvement toolbox including clinical practice guidelines and printable patient education materials., Results: In the formative evaluation of the first 2 chlamydia modules, data regarding the recruitment, enrollment, participation, and reminders have been examined. Preliminary evaluation data from a randomized, controlled trial has tested the effectiveness of this intervention in improving chlamydia screening rates with a significant increase in intervention physicians' chlamydia knowledge, attitude, and skills compared to those of a control group., Conclusions: The application of theory in the development and evaluation of a Web-based continuing medical education intervention offers valuable insight into World Wide Web technology's influence on physician performance and the quality of medical care.

Objective: To design an individualized Web-based continuing medical education (CME) program to improve practicing physicians' chlamydial screening rates., Description: Often unrecognized and untreated, chlamydial infections in young women may cause pelvic inflammatory disease, infertility, and ectopic pregnancy and facilitate the acquisition of HIV. The National Committee for Quality Assurance in 2001 reported chlamydia screening rates to be 23.6% for 16-20-year-olds and 18.3% for 21-26-year-olds. In a collaborative project an academic medical center and a large national managed care organization have developed four tailored Web-based modules for primary care physicians with the goal of improving rates of screening for chlamydia. Each module includes: (1) individual office chlamydial screening rates; (2) interactive cases with real-time comparison of answers with those of peers; (3) a toolbox of office support materials, including patient education materials and guideline summaries; and (4) real-time tailoring of the Web pages based on physicians' interactions with module. Readiness to change and barriers impeding change are assessed during interaction with the module and multiple pathways are created in real time for each physician. Physicians' perceptions of the prevalence of chlamydia in their patient populations and the rate of sexual activity among adolescent girls are also assessed. These variables have been correlated in other studies with low rates of chlamydial screening. Inaccurate perceptions of these variables are considered to constitute a precontemplative stage of change. Specific messages are designed to facilitate increased awareness of chlamydia prevalence, level of sexual activity, and the consequences of failure to screen. For physicians who are aware of the nature and scope of the problems related to chlamydia, messages are tailored to assist them in reducing barriers to screening. A randomized trial of a national sample of primary care physicians is being conducted to determine the effectiveness of this intervention in improving physicians' chlamydial screening rates in sexually active women 16-26 years of age., Discussion: While the Internet offers an educational distribution system accessible to practicing physicians, most CME online programs are text-based and infrequently interactive or guideline-based. It is unlikely that these programs have broad impact on physicians' practice patterns. Neither the broad capacities of Web technologies nor the evidence of effective methods for influencing physicians' practice patterns has influenced the design of most CME programs. The innovative course described above provides individual office feedback on performance, compares physicians' responses with those of their peers, gathers responses to determine physicians' readiness to change practices, and provides branching pathways "on-the-fly" individualized to these responses. The module format is easily adapted to other diseases, able to be linked in an automated fashion to administrative data files, and relatively low in cost to support.

Background: Millions of consumers have accessed health information online. However, little is known about their health status., Objective: To explore use of Internet health information among those who were sicker (fair/poor general health status) compared with those reported being healthier., Methods: A national, random-digit telephone survey by the Pew Internet & American Life Project identified 521 Internet users who go online for health care information. Our primary independent variable was general health status rated as excellent, good, fair, or poor. Patterns of Internet use, and types of information searched were assessed., Results: Among the 521 users, 64% were female, most (87%) were white, and median age was 42 years. Most individuals indicated that they learned something new online (81%) and indicated that they believe most information on the Internet (52%). Compared with those with excellent/good health, those with fair/poor health (N = 59) were relative newcomers to the Internet but tended to use the Internet more frequently, were more likely to use online chats, were less likely to search for someone other than themselves, and were more likely to talk about the new information with their physician (odds ratio 3.3 [95% confidence interval 1.8-6.3]), after adjustment for age, education and income., Conclusions: Health care professionals should be aware that their sicker patients are more likely to ask them about information they found online. Physicians, public health professionals, and eHealth developers should work together to educate patients about searching for health information online and to provide tools for them to navigate to the highest quality information.

Introduction: CME providers may be interested in identifying effective marketing strategies to direct users to specific content. Online advertisements for recruiting participants into activities such as clinical trials, public health programs, and continuing medical education (CME) have been effective in some but not all studies. The purpose of this study was to compare the impact of 2 marketing strategies in the context of an online CME cultural competence curriculum (www.c-comp.org). Methods: In an interrupted time-series quasi-experimental design, 2 marketing strategies were tested: (1) wide dissemination to relevant organizations over a period of approximately 4 months, and (2) Internet paid search using Google Ads (5 consecutive 8-week periods--control 1, cultural/CME advertisement, control 2, hypertension/ content advertisement, control 3). Outcome measures were CME credit requests, Web traffic (visits per day, page views, pages viewed per visit), and cost. Results: Overall, the site was visited 19,156 times and 78,160 pages were viewed. During the wide dissemination phase, the proportion of visits requesting CME credit decreased between the first (5.3%) and second (3.3%) halves of this phase (p = 0.04). During the Internet paid search phase, the proportion of visits requesting CME credit was highest during the cultural/CME advertisement period (control 1, 1.4%; cultural/CME ad, 4.3%; control 2, 1.5%; hypertension/content ad, 0.6%; control 3, 0.8%; p less than 0.001). All measures of Web traffic changed during the Internet paid search phase (p less than 0.01); however, changes were independent of the advertisement periods. The incremental cost for the cultural advertisement per CME credit requested was US $0.64. Discussion: Internet advertisement focusing on cultural competence and CME was associated with about a threefold increase in requests for CME credit at an incremental cost of under US $1; however, Web traffic changes were independent of the advertisement strategy. (Contains 2 tables and 2 figures.)

Introduction: Physician use of the Internet for practice improvement has increased dramatically over the last decade, but research shows that many physicians choose not to participate. The current study investigated the association of specific physician characteristics with enrollment rates and intensity of participation in a specific Internet-delivered educational intervention to improve care to post-myocardial infarction (MI) patients. Methods: Primary-care physicians were recruited for participation in a randomized controlled trial designed to compare effectiveness of an intervention Web site versus a control Web site in the management of adult chronic disease. Physicians were informed that the intervention focused on ambulatory post-myocardial infarction patients. Physician characteristics were obtained from a commercial vendor with data merged from the American Medical Association and Alabama State Licensing Board. Enrollment and Web use were tracked electronically. Results: Out of a sample of 1337 eligible physicians, 177 (13.2%) enrolled in the study. Enrollment was higher for physicians with more post-MI patients (greater than or equal to 20 vs less than 20 patients, 15.3% vs 9.3%, P = 0.002) and for those practicing in rural compared to urban areas (16.3% vs 12.1%, P = 0.046). Intensity of use of the Internet courses after initial enrollment was not predicted by physician characteristics in the current sample. Discussion: Physicians with more post-MI patients and rural practice location were found to predict enrollment in an Internet-delivered continuing medical education (CME) intervention designed to improve care for post-MI patients. These factors predicted program interest but not program use. More research is needed to replicate these findings to investigate variables that determine physician engagement in Internet CME. (Contains 2 tables.)

This research tests the independent contribution of social capital and the use of the internet to obtain health information to support maternal-child communication about peer pressure to have sex among Puerto Rican families. A sample of 413 Puerto Rican households in Springfield, MA provides the data to independently test these hypotheses. The results of a logistic regression model suggest that Puerto Rican mothers with increased social capital and who accessed the internet for health information are more likely to communicate with their adolescent children about peer pressure to have sex. The combination of these two mechanisms provide opportunities to convey culturally generated resources to Puerto Rican mothers to assist them in helping their children develop healthy sexual behaviors. [ABSTRACT FROM AUTHOR]

Purpose: This study evaluated a culturally relevant, social cognitive theory–based, Internet-enhanced physical activity (PA) pilot intervention developed for overweight/obese African American (AA) female college students. Design: Using a 3-month, single group, pretest–posttest design, participants accessed a culturally relevant PA promotion website and engaged in four moderate-intensity PA sessions each week. Results: Study completers (n = 25, mean age = 21.9 years) reported a decrease in sedentary screen time (p < .0001); however, no changes in moderate-to-vigorous PA were reported (p = .150). A significant increase in self-regulation for PA (p < .0001) and marginally significant increases in social support (p = .052) and outcome expectations (p = .057) for PA were observed. No changes in body mass index (p = .162), PA enjoyment (p = .151), or exercise self-efficacy (p = .086) were reported. Conclusions: Findings of this exploratory study show some preliminary support for Internet-enhanced approaches to promote PA among overweight/obese AA women. Implications for Practice: Future studies with larger samples are needed to further explore culturally relevant Internet-enhanced PA programs in this underserved population. [ABSTRACT FROM AUTHOR]

The article focuses on the outcome of the development and implementation of two Internet-enhanced culturally relevant physical activity interventions for overweight African-American female college students and the lessons learned from the development. Topics discussed include the health benefits of physical activity (PA) in terms of weight loss, the incorporation of new technologies into Internet-based PA programs and the importance of maintaining frequent contact with participants.

The article discusses the results of a study which evaluated an Internet-delivered intervention to improve cardiovascular care for ambulatory patients who survived myocardial infarction (MI). An overview of components of a typical Internet-delivered intervention is given, including practice guidelines, quarterly educational modules and monthly literature summaries. The study showed that Internet-delivered intervention does not provide significant improvement on cardiovascular management.

Evaluation of Internet-delivered continuing education for health care providers requires appropriate consideration of their level of participation. To fully assess participation requires multidimensional measures, including factors such as the volume of participation (page views), frequency (visits), variety (components accessed by each provider), and duration (months of activity). We calculated crude and refined (adjusted for study design) measures and then compared these measures across three longitudinal Internet-delivered continuing education to health care providers (N = 429). We found that participation varied across study, varied by factor and varied by specific measure. Correlation between crude and refined measures within a factor and across factors differed significantly. Participation assessment of internet-delivered interventions varies by the selection of measure and factor. Further research assessing the potential for these measures to predict intervention effectiveness is needed. [ABSTRACT FROM AUTHOR]