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Applying both theoretical perspectives and empirical evidence, we address 2 key questions regarding shared decision making (SDM): 1) When should SDM be more patient driven, and when should it be more provider driven? and 2) Should health care providers match their SDM style/strategy to patient needs and preferences? Self-determination theory, for example, posits a distinction between autonomy and independence. A patient may autonomously seek their health care provider's input and guidance, perhaps due to low perceived competence, low coping resources, or high emotional arousal. Given their need state, they may autonomously require nonindependence. In this case, it may be more patient centered and need supportive to provide more provider-driven care. We discuss how other patient characteristics such as personality attributes, motivational state, and the course of illness and other parameters such as time available for an encounter may inform optimal provider decision-making style and strategy. We conclude that for some types of patients and clinical circumstances, a more provider-driven approach to decision making may be more practical, ethical, and efficacious. Thus, while all decision making should be patient centered (i.e., it should consider patient needs and preferences), it does not always have to be patient driven. We propose a flexible model of SDM whereby practitioners are encouraged to tailor their decision making behaviors to patient needs, preferences, and other attributes. Studies are needed to test whether matching decision-making behavior based on patient states and traits (i.e., achieving concordance) is more effective than simply providing all patients with the same type of decision making, which could be tested using matching/mismatching designs.

Background: High quality multidisciplinary care improves outcomes for rectal cancer (RC) but is not consistently provided. Our objective was to understand surgeons' barriers to RC care., Methods: Semi-structured interviews were conducted with 18 surgeons from 10 Michigan hospitals. Reports of hospital performance were shared. Interview transcripts were dual coded; data were reduced into emergent themes; and disagreements were resolved by discussion., Results: Barriers to high quality care included negative attitudes, (resistance to change; not taking responsibility) lack of training/experience, complex care coordination, and financial disincentives. Facilitators included providers' positive attitudes and relationships, training/experience, surgeon leadership (development of protocols), patient-level systems of care (patient navigator), and higher-level support (cancer center reviews quality data). Themes were incorporated into an explanatory framework, with patient, provider, and systems domains., Conclusions: In this qualitative study of RC surgeons, we identified barriers to and facilitators of high-quality care. The framework developed will facilitate the design of quality improvement interventions., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Arab American women have preferred women physicians of their own culture in the past. The primary aim of this study is to determine the current influence of religion/culture among MENA women and their preferences for physicians of same sex, culture, and religion on the avoidance and uncomfortableness of routine and women's health exams., Methods: A cross sectional community survey including religiosity and the importance of physician matched sex, culture, and religion was completed. Outcome measures were avoidance of a routine physical exam, or a women's health exam because of religious/cultural issues; and the uncomfortableness of the women's health exam. Linear regression modeling was used to evaluate the association between outcomes and potential predictors, with significance assessed using a bootstrap method., Findings: The responses of 97 MENA women 30-65 years old showed that MENA women agreed that they would avoid routine health exams because of religious/cultural issues if their physician was of the same religion or culture as they were ( p < 0.001, p < 0.05, respectively) or they had less education ( p < 0.05). MENA women also avoided women's health exams due to religious/cultural issues if her physician was of the same religion as she ( p < 0.01)., Interpretation: MENA women 30-65 years old may no longer be bound to a female physician of their same religion/culture for their health exams., Competing Interests: Declaration of interests The authors declare that they have no conflict of interest.

Background and Objectives: Youth violence is an alarming public health problem, yet, violence screening and interventions are not systematically offered in primary care (PC). This paper describes data from a pilot effectiveness-implementation trial of an efficacious youth violence prevention programme (SafERteens)., Methods: The study was conducted in two PC clinics: a university-affiliated satellite clinic and a community health centre. In phase 1, we obtained stakeholder feedback to customise the SafERteens package and enrolled a comparison group of adolescents (age 14-18) seeking care in two clinics. In phase 2, clinical staff delivered the SafERteens-PC intervention with adolescents, which is a single, behavioural health therapy session delivered one-on-one from clinic providers to youth patients, followed by text message (TM) reminders. In phase 3, we assessed planned maintenance. All participants reported past-year violent behaviour at intake and completed a 3-month follow-up assessment., Results: Based on stakeholder interviews (n=13), we created a web-based SafERteens-PC programme package, including a three-item past-year violence screen, 30 min motivational interviewing-based brief intervention delivery tool, training videos and 2 months of TM boosters. We enrolled a comparison group (n=49) first, then an intervention group (n=61). Intervention delivery characteristics varied by clinic, including completion of intervention (75.9%; 62.5%), modality (100% delivered via telehealth; 60% via telehealth/40% in-person) and enrolment in TMs (81.8%; 55.0%); 91.8% completed the follow-up. Using an intention-to-treat approach, the intervention group showed significantly greater reductions in severe peer aggression (p<0.05), anxiety (p<0.05) and substance use consequences (p<0.05) relative to the comparison group. Participant and staff feedback were positive and identified challenges to long-term implementation, such as lack of availability of reimbursement for youth violence prevention., Conclusions: If these challenges could be addressed, routine provision of behavioural health services for violence prevention in PC could have high impact on health outcomes for adolescents., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. No commercial re-use. See rights and permissions. Published by BMJ.)

The cervical cancer screening behaviors of Arab American women are not adequately understood, in part because Middle Eastern North African (MENA) descent is not a US Census category. Others have shown decreased cervical cancer screening in this race of women. Our primary aim is to evaluate the predictors of cervical cancer screening among MENA, White and Black women of southeast Michigan. A community-wide health survey reached MENA, White and Black populations asking self-report questions about health behaviors, attitudes, and medical history. Cervical cancer screening was considered up-to-date if it was reported to have occurred within the past three years. Survey responses were limited to women 30-65 years old and were analyzed with inferential and logistic regression models to determine risk factors for cervical cancer screening. Overall, 78% reported cervical cancer screening within the past three years. MENA women screened less often if time in the US was less than ten years (aOR 0.24 (0.05, 0.76)) compared to more than ten years and if single (aOR 0.27 (0.07, 0.97)) compared to married. Religion was not associated with screening in any study population. Those of all races without insurance screened significantly less often than those with insurance. The barriers to cervical cancer screening among MENA women are not associated with religion but instead with lack of insurance and length of time residing in the US., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Food insecurity (FI) has been associated with poor access to health care. It is unclear whether this association is beyond that predicted by income, education, and health insurance. FI may serve as a target for intervention given the many programs designed to ameliorate FI. We examined the association of FI with being up-to-date to colorectal cancer and breast cancer screening guidelines., Methods: Nine NCI-designated cancer centers surveyed adults in their catchment areas using demographic items and a two-item FI questionnaire. For the colorectal cancer screening sample (n = 4,816), adults ages 50-75 years who reported having a stool test in the past year or a colonoscopy in the past 10 years were considered up-to-date. For the breast cancer screening sample (n = 2,449), female participants ages 50-74 years who reported having a mammogram in the past 2 years were up-to-date. We used logistic regression to examine the association between colorectal cancer or breast cancer screening status and FI, adjusting for race/ethnicity, income, education, health insurance, and other sociodemographic covariates., Results: The prevalence of FI was 18.2% and 21.6% among colorectal cancer and breast cancer screening participants, respectively. For screenings, 25.6% of colorectal cancer and 34.1% of breast cancer participants were not up-to-date. In two separate adjusted models, FI was significantly associated with lower odds of being up-to-date with colorectal cancer screening [OR, 0.7; 95% confidence interval (CI), 0.5-0.99)] and breast cancer screening (OR, 0.6; 95% CI, 0.4-0.96)., Conclusions: FI was inversely associated with being up-to-date for colorectal cancer and breast cancer screening., Impact: Future studies should combine FI and cancer screening interventions to improve screening rates., (©2022 American Association for Cancer Research.)

Firearm-related injury is a major public health concern in the U.S. Experience of racism and discrimination can increase the risk of minority group members engaging in or being victims of firearm-related violence. Given the increased racism endured by Asian Americans during the COVID-19 pandemic, it is imperative to understand firearm-related behaviors in this population. The purpose of this study was to examine how Asian Americans' racism and discrimination experiences were related to firearm-related behaviors during the COVID-19 pandemic. Cross-sectional data were collected between December 2020 and January 2021 from a national sample of 916 Asian Americans. Measures included demographics, firearm-related risks, and three measures of racism/discrimination experiences since the start of the COVID-19 pandemic. Among individuals who purchased a gun since the start of the pandemic, 54.6% were first-time gun owners. Among household gun owners, 42.8% stored loaded guns and 47.1% stored guns unlocked. More than 38% of individual gun owners have carried a gun more frequently since the pandemic. After controlling for family firearm ownership and demographics, regression analyses showed that Asian Americans who experienced racial discrimination were more likely to purchase a gun and ammunition and intend to purchase more ammunition during the COVID-19 pandemic. AAs who perceived more cultural racism were more likely to purchase a gun. Individuals who reported higher anticipatory racism-related stress reported greater intent to purchase guns. Our findings suggest an urgent need to investigate further the compounded effects of racism, the COVID-19 pandemic, and firearm-related behaviors in this population., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2022 The Author(s).)

Background: Low- and middle-income countries (LMICs) are experiencing major increases in diabetes and cardiovascular conditions linked to overweight and obesity. Lifestyle interventions such as the United States National Diabetes Prevention Program (DPP) developed in high-income countries require adaptation and cultural tailoring for LMICs. The objective of this study was to evaluate the efficacy of "Lifestyle Africa," an adapted version of the DPP tailored for an underresourced community in South Africa compared to usual care., Methods and Findings: Participants were residents of a predominantly Xhosa-speaking urban township of Cape Town, South Africa characterized by high rates of poverty. Participants with body mass index (BMI) ≥ 25 kg/m2 who were members of existing social support groups or "clubs" receiving health services from local nongovernmental organizations (NGOs) were enrolled in a cluster randomized controlled trial that compared Lifestyle Africa (the intervention condition) to usual care (the control condition). The Lifestyle Africa intervention consisted of 17 video-based group sessions delivered by trained community health workers (CHWs). Clusters were randomized using a numbered list of the CHWs and their assigned clubs based on a computer-based random allocation scheme. CHWs, participants, and research team members could not be blinded to condition. Percentage weight loss (primary outcome), hemoglobin A1c (HbA1c), blood pressure, triglycerides, and low-density lipoprotein (LDL) cholesterol were assessed 7 to 9 months after enrollment. An individual-level intention-to-treat analysis was conducted adjusting for clustering within clubs and baseline values. Trial registration is at ClinicalTrials.gov (NCT03342274). Between February 2018 and May 2019, 782 individuals were screened, and 494 were enrolled. Participants were predominantly retired (57% were receiving a pension) and female (89%) with a mean age of 68 years. Participants from 28 clusters were allocated to Lifestyle Africa (15, n = 240) or usual care (13, n = 254). Fidelity assessments indicated that the intervention was generally delivered as intended. The modal number of sessions held across all clubs was 17, and the mean attendance of participants across all sessions was 61%. Outcome assessment was completed by 215 (90%) intervention and 223 (88%) control participants. Intent-to-treat analyses utilizing multilevel modeling included all randomized participants. Mean weight change (primary outcome) was -0.61% (95% confidence interval (CI) = -1.22, -0.01) in Lifestyle Africa and -0.44% (95% CI = -1.06, 0.18) in control with no significant difference (group difference = -0.17%; 95% CI = -1.04, 0.71; p = 0.71). However, HbA1c was significantly lower at follow-up in Lifestyle Africa compared to the usual care group (mean difference = -0.24, 95% CI = -0.39, -0.09, p = 0.001). None of the other secondary outcomes differed at follow-up: systolic blood pressure (group difference = -1.36; 95% CI = -6.92, 4.21; p = 0.63), diastolic blood pressure (group difference = -0.39; 95% CI = -3.25, 2.30; p = 0.78), LDL (group difference = -0.07; 95% CI = -0.19, 0.05; p = 0.26), triglycerides (group difference = -0.02; 95% CI = -0.20, 0.16; p = 0.80). There were no unanticipated problems and serious adverse events were rare, unrelated to the intervention, and similar across groups (11 in Lifestyle Africa versus 13 in usual care). Limitations of the study include the lack of a rigorous dietary intake measure and the high representation of older women., Conclusions: In this study, we found that Lifestyle Africa was feasible for CHWs to deliver and, although it had no effect on the primary outcome of weight loss or secondary outcomes of blood pressure or triglycerides, it had an apparent small significant effect on HbA1c. The study demonstrates the potential feasibility of CHWs to deliver a program without expert involvement by utilizing video-based sessions. The intervention may hold promise for addressing cardiovascular disease (CVD) and diabetes at scale in LMICs., Trial Registration: ClinicalTrials.gov NCT03342274., Competing Interests: The authors have declared that no competing interests exist.

There is an increased interest in the use of personalized medicine approaches in the prevention or treatment of obesity, however, few studies have used these approaches to identify individual differences in treatment effects. The current study demonstrates the use of the predicted individual treatment effects framework to test for individual differences in the effects of the ACTION-PAC intervention, which targeted the treatment and prevention of obesity in a high school setting. We show how methods for personalized medicine can be used to test for significant individual differences in responses to an intervention and we discuss the potential and limitations of these methods. In our example, 25% of students in the preventive intervention, were predicted to have their BMI z-score reduced by 0.39 or greater, while at other end of the spectrum, 25% were predicted to have their BMI z-score increased by 0.09 or more. In this paper, we demonstrate and discuss the process of using methods for personalized medicine with interventions targeting adiposity and discuss the lessons learned from this application. Ultimately, these methods have the potential to be useful for clinicians and clients in choosing between treatment options, however they are limited in their ability to help researchers understand the mechanisms underlying these predictions., (© 2022. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Social factors (e.g. housing, food security, etc.) contribute significantly to health. The purpose of this study is to describe social risk and social exclusion factors in one of the largest Middle Eastern and North African (MENA) populations in the U.S. and their association with health outcomes. We conducted a cross-sectional study with a community convenience sample of 412 adults who self-identify as MENA. Weighted, adjusted linear regression models were used to examine relationships of interest. Prevalent social risks included transportation barriers to healthcare (33%), food insecurity (33%), and financial strain (25%). In adjusted models, perception of being treated unfairly (Estimate (SE) 0.08 (0.04), p < 0.05) and fear of deportation (0.26 (0.06), p < 0.001) were associated with more social risk factors. More social risk factors were associated with worse self-reported health (0.09 (0.03), p < 0.01), more chronic conditions (0.11 (0.03), p < 0.004), and more mental health symptoms (0.34 (0.14) p < 0.01).Social risk is high among those perceiving unfairness and fear deportation. Those with more social risk factors reported worse health. These findings have implications for social needs screening and referral models that can best serve U.S. MENA sub-populations., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Oxaliplatin-induced peripheral neuropathy (OIPN) is prevalent among gastrointestinal cancer survivors and often impairs quality of life (QOL)., Objective: This pilot randomized controlled trial aimed to explore the effect of an 8-week home-based brisk walking (the "MI-Walk") intervention on (1) OIPN severity and (2) QOL at 8 weeks, compared with physical activity (PA) education alone in oxaliplatin-receiving adults with gastrointestinal cancer., Interventions/methods: Participants (N = 57) recruited from 5 infusion sites received PA education at their second oxaliplatin visit, followed by phone assessments of adverse events over 8 weeks. Half (n = 29) received additional MI-Walk intervention motivational supports (eg, a Fitbit Charge 2 and motivational enhancement therapy sessions). Self-reported OIPN, QOL, and PA were measured before and after intervention., Results: The intervention compared with the control condition had no effect on sensory OIPN (mean difference [] = -0.01; P > .99), motor OIPN (=2.39; P = .17), and QOL (= -1.43; P > .99). Eight-week sensory (=11.48 ± 0.38) and motor OIPN severities ( = 7.48 ± 0.36) were mild but higher than baseline (P ≤ .01). Self-reported PA level increased over time in both groups (=44.85; P = .01). Averaging ≥225 moderate to vigorous PA minutes per week led to less sensory OIPN, particularly finger/hand tingling (= -26.35; P = .01)., Conclusions: This study failed to detect beneficial effects of the MI-Walk intervention; however, the findings suggest that aerobic walking may blunt but not completely prevent OIPN. Further research is necessary., Implications for Practice: Although the effectiveness of brisk walking in reducing OIPN is unclear, this study supports prior evidence that moderate to vigorous PA is beneficial and safe during chemotherapy treatment., Competing Interests: The authors have no conflicts of interest to disclose., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To assess the accuracy of 5 subjective self-assessment tools (3 adherence measures and 2 psychometric scales) and pharmacy refill data in predicting objective electronically monitored nonadherence., Design: Prospective cohort study., Participants: Glaucoma patients (> 40 years old, >1 medication with poor self-reported adherence) were recruited from University of Michigan Kellogg Eye Center for a study assessing the impact of a personalized glaucoma coaching program on medication adherence., Methods: Participants completed an initial assessment including 5 self-assessment tools and a 3-month period of electronic monitoring of glaucoma medication adherence (AdhereTech); pharmacy refill data were obtained. Electronically monitored adherence was calculated monthly as the percentage of doses taken on time. The median of these adherence rates was designated as baseline adherence. Patients with adherence of ≤80% by electronic monitoring were considered nonadherent. Self-assessment tools were scored, and pharmacy refill data were summarized as the proportion of days covered. Correlation between measures of adherence was estimated with Pearson and Spearman correlation coefficients. Receiver operating characteristic curves, including estimation of area under the curve (AUC), sensitivity, specificity, and accuracy were used to compare measures of adherence with respect to predicting electronically monitored nonadherence., Main Outcome Measures: Accuracy of self-reported and pharmacy refill data adherence measures in predicting electronically monitored nonadherence., Results: Ninety-five patients completed 3 months of electronic monitoring with a median monthly adherence of 74 (± 21%); 53 patients (56%) were nonadherent. Pharmacy refill data were not correlated significantly with electronically monitored medication adherence (r = 0.12; P = 0.2). Of all the measures, a single-item adherence question ("Over the past month, what percentage of your drops do you think you took correctly?") showed the largest correlation with median electronically monitored adherence (r = 0.47; P < 0.0001), largest AUC for predicting nonadherence (AUC = 0.76 [95% confidence interval [CI], 0.66-0.87]), best accuracy (71% [95% CI, 61%-82%]), and good sensitivity (84% [95% CI, 73%-96%])., Conclusions: The single-item question was the most accurate in predicting electronically monitored nonadherence among participants with poor self-reported adherence. In clinical practice, where alternatives are too resource intensive, this free single-item screening question can help to identify glaucoma patients at risk of poor medication adherence with reasonable accuracy., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Social media provides an effective tool to reach, engage, and connect smokers in cessation efforts. Our team developed a Facebook group, CAN Quit (Connecting Alaska Native People to Quit smoking), to promote use of evidence-based smoking cessation resources for Alaska Native people living in Alaska, which are underused despite their effectiveness. Often separated by geography and climate, Alaska Native people prefer group-based approaches for tobacco cessation that support their culture and values. Such preferences make Alaska Native people candidates for social media-based interventions that promote connection. This viewpoint discusses the steps involved and lessons learned in building and beta-testing our Facebook group prototype, which will then be evaluated in a pilot randomized controlled trial. We describe the process of training moderators to facilitate group engagement and foster community, and we describe how we developed and tested our intervention prototype and Facebook group. All parts of the prototype were designed to facilitate use of evidence-based cessation treatments. We include recommendations for best practices with the hope that lessons learned from the CAN Quit prototype could provide a model for others to create similar platforms that benefit Alaska Native and American Indian people in the context of smoking cessation., (©Pamela S Sinicrope, Colleen D Young, Ken Resnicow, Zoe T Merritt, Clara R McConnell, Christine A Hughes, Kathryn R Koller, Martha J Bock, Paul A Decker, Christie A Flanagan, Crystal D Meade, Timothy K Thomas, Judith J Prochaska, Christi A Patten. Originally published in the Journal of Medical Internet Research (https://www.jmir.org), 17.02.2022.)

Background: Walking therapy improves functional outcomes in patients with peripheral artery disease (PAD). Less is known about the additive benefit of a dietary intervention., Objective: Our objectives were to develop a smartphone app and, as a pilot, explore its potential efficacy as compared to motivational interviewing (MI) to increase walking distance and promote weight loss in overweight/obese adults with PAD., Methods: We conducted a 3-month, 2-arm randomized pilot study at the University of Kansas. Inclusion criteria were BMI >27 kg/m 2 and symptomatic PAD, defined by an ankle-brachial index <0.9. Patients were randomized into 2 groups: MI, delivered through in-person and telephone counseling, and app, a mobile smartphone app. Both interventions encouraged walking for exercise and healthy dietary habits (increasing fruits and vegetables and whole grains while reducing fat and sugary drinks). We assessed medical history at baseline. At baseline and 3 months, participants completed an assessment of 6-minute walking distance, weight, quality of life, exercise behaviors, and dietary habits. The primary outcome was 3-month change in walking distance. Secondary outcomes were changes in weight, quality of life, exercise behaviors, and dietary habits. We used a Wilcoxon rank-sum test to analyze the primary and secondary outcomes at 3 months within the MI and app groups and to compare the changes between the groups with adjustment for baseline., Results: We randomized 29 participants with a mean age of 66.03 (SD 8.12) years; 25 participants completed the trial. At baseline, mean walking distance among completers was 260.40 (SD 94.32) meters and 326.15 (SD 69.28) meters for MI and app participants, respectively. At 3 months, the mean walking distance was 298.67 (SD 101.20) meters and 331.19 (SD 58.63) meters for MI and app participants, respectively (group difference P=.03, adjusting for baseline). Increase in walking distance at 3 months was 40.5 meters (95% CI 6.77 to 61.34; P=.02) in MI group. At baseline, mean body weight was 253.10 (SD 59.45) lbs and 225.13 (SD 58.93) lbs for MI and app participants, respectively. At 3 months, mean body weight was 242.14 (SD 58.54) lbs and 223.44 (SD 59.54) lbs for MI and app, respectively (group difference P=.006, adjusting for baseline). Pre-post study decrease in weight was 10.1 lbs (95% CI -17.9 to -3.0) and 2.3 lbs (95% CI -3.4 to -0.7) in MI and app group, respectively. Comparing baseline to 3 months, there were no statistically significant differences in quality of life, exercise behaviors, or dietary habits., Conclusions: Our study demonstrates that MI can promote walking and weight loss in overweight/obese adults with PAD. The smartphone app showed a small weight loss but no statistically significant increase in walking distance. As this was a pilot study, future large-scale studies are needed to replicate the efficacy of MI to promote weight loss in overweight or obese adults with PAD., Trial Registration: ClinicalTrials.gov NCT03694652; https://clinicaltrials.gov/ct2/show/NCT03694652., (©Tracie Collins, Mugur Geana, Kathryn Overton, Mary Benton, Liuqiang Lu, Faarina Khan, Mason Rohleder, Jasjit Ahluwalia, Ken Resnicow, Yiliang Zhu. Originally published in JMIR Formative Research (https://formative.jmir.org), 03.02.2022.)

Aims: The purpose of this study was to examine whether pandemic exposure impacted unmet social and diabetes needs, self-care behaviors, and diabetes outcomes in a sample with diabetes and poor glycemic control., Methods: This was a cross-sectional analysis of participants with diabetes and poor glycemic control in an ongoing trial (n = 353). We compared the prevalence of unmet needs, self-care behaviors, and diabetes outcomes in successive cohorts of enrollees surveyed pre-pandemic (prior to March 11, 2020, n = 182), in the early stages of the pandemic (May-September, 2020, n = 75), and later (September 2020-January 2021, n = 96) stratified by income and gender. Adjusted multivariable regression models were used to examine trends., Results: More participants with low income reported food insecurity (70% vs. 83%, p < 0.05) and needs related to access to blood glucose supplies (19% vs. 67%, p < 0.05) during the pandemic compared to pre-pandemic levels. In adjusted models among people with low incomes, the odds of housing insecurity increased among participants during the early pandemic months compared with participants pre-pandemic (OR 20.2 [95% CI 2.8-145.2], p < 0.01). A1c levels were better among participants later in the pandemic than those pre-pandemic (β = -1.1 [95% CI -1.8 to -0.4], p < 0.01), but systolic blood pressure control was substantially worse (β = 11.5 [95% CI 4.2-18.8, p < 0.001)., Conclusion: Adults with low-incomes and diabetes were most impacted by the pandemic. A1c may not fully capture challenges that people with diabetes are facing to manage their condition; systolic blood pressures may have worsened and problems with self-care may forebode longer-term challenges in diabetes control., (Copyright © 2021 Primary Care Diabetes Europe. Published by Elsevier Ltd. All rights reserved.)

A recent childhood vaccine promotion intervention trial showed no effects on vaccination outcomes relative to usual care. The purpose of this paper was to test assumptions and theory-based relationships underlying hypothesised mechanisms for two vaccine promotion educational websites (one tailored to parental values, beliefs, and intentions; one untailored) compared with usual care. This is a secondary analysis of a three-arm randomized controlled trial. Parental vaccine values, hesitancy, attitudes, and intention to vaccinate surveys were administered at baseline (≤2 months) and at 4-6 and 10-12 months of age. Vaccination was assessed using electronic health records. Analyses included random coefficient models and risk differences with exact confidence limits. Parental vaccine values were mostly stable over time. Vaccine attitudes were generally positive, with no differences among study arms. Both tailored and untailored website arms showed similar increases in intention to vaccinate more than usual care. Positive changes in intentions were associated with lower rates of late vaccination. Although attitudes and intentions predicted vaccination behavior and the intervention increased intention to vaccinate all on time, the web-based education and values-tailored messaging approaches were not effective at increasing vaccination rates. Intentions are necessary but insufficient targets for vaccine promotion interventions., (© 2021 The International Association of Applied Psychology.)

Background: The concomitant use of anticoagulant and antiplatelet medications increases the risk of upper gastrointestinal (GI) bleeding. Two underused evidence-based practices (EBPs) can reduce the risk: de-prescribe unnecessary antiplatelet therapy or initiate a proton pump inhibitor. We describe the development of a multicomponent intervention to increase use of these EBPs in patients treated with warfarin and followed by an anticoagulation monitoring service (AMS), and the design of a pilot pragmatic implementation trial., Methods: A participatory planning group iteratively used Implementation Mapping and the Multiphase Optimization Strategy to develop implementation strategies and plan the trial. Informed by qualitative interviews with patients and clinicians, we drew on several implementation science theories, as well as self-determination theory, to design interventions. For patients, we developed an activation guide to help patients discuss the EBPs with their clinicians. For clinicians, we developed two electronic health record (EHR)-based interventions: (1) clinician notification (CN) consists of a templated message that identifies a patient as high risk, summarizes the EBPs, and links to a guidance statement on appropriate use of antiplatelet therapy. (2) Clinician notification with nurse facilitation (CN+NF) consists of a similar notification message but includes additional measures by nursing staff to support appropriate and timely decision-making: the nurse performs a chart review to identify any history of vascular disease, embeds indication-specific guidance on antiplatelet therapy in the message, and offers to assist with medication order entry and patient education. We will conduct a pilot factorial cluster- and individual-level randomized controlled trial with a primary objective of evaluating feasibility. Twelve clinicians will be randomized to receive either CN or CN+NF for all their patients managed by the AMS while 50 patients will be individually randomized to receive either the activation guide or usual care. We will explore implementation outcomes using patient and clinician interviews along with EHR review., Discussion: This pilot study will prepare us to conduct a larger optimization study to identify the most potent and resource conscious multicomponent implementation strategy to help AMSs increase the use of best practices for upper GI bleeding risk reduction., Trial Registration: ClinicalTrials.gov NCT05085405 . Registered on October 19, 2021-retrospectively registered., (© 2022. The Author(s).)

Objective: Cost-related nonadherence to health maintenance behaviors is common in the general population, yet we know little about these behaviors in Middle East and North African (MENA) Americans. We examined cost-related nonadherence (CRN) in the MENA community in SE Michigan to determine demographic predictors, and risk and protective factors., Design Setting and Participants: We used data from a cross-sectional convenience sample of MENA adults (N=398) conducted May-September 2019 to identify relevant demographic predictors, as well as the association between individual health, social, and clinical factors and the likelihood of reporting CRN., Methods and Measures: CRN was defined by whether respondents reported any of the following: that they took less medicine, skipped doses, or delayed getting a prescription filled. Other factors included patient/provider communication and racial concordance, mental health distress, food insecurity and insurance status. We used multivariable logistic regression models to determine association of these health and social factors with CRN., Results: Those with highest incomes were least likely to report CRN. Participants with private insurance and with no coverage were more likely to report CRN compared with those with Medicaid coverage. Risk factors for CRN included food insecurity and mental health distress, though strong patient/provider communication was protective of CRN., Discussion: The risk factors for CRN in the MENA community align with risk factors in the general population. As provider communication is protective of CRN, interventions focused on improving patient/provider communication may serve as a way to protect against financially motivated medication nonadherence., Competing Interests: Competing Interests: None declared., (Copyright © 2022, Ethnicity & Disease, Inc.)

Objective: To determine baseline characteristics of a group of Samoans/Tongans in Southern California at risk for type 2 diabetes mellitus and identify barriers, cultural factors, and readiness and capacity to implement a culturally tailored Diabetes Prevention Program (DPP) in a faith-based setting., Design: A mixed-methods pilot that included piloting modified DPP sessions, conducting a survey, and focus groups (N = 4)., Setting: Samoan/Tongan faith-based organizations., Participants: Samoan/Tongan church members in Southern California who were interested in lifestyle behavior change., Main Outcome Measures: Surveys assessing sociodemographic, acculturation, health status, food insecurity, and psychosocial factors. Focus groups focusing on attitudes toward the curriculum, opportunities for tailoring, and specific barriers/facilitators for healthy weight, nutrition, and physical activity., Results: Participants (N = 47) were on average 42 years old, female (57%), and identified as Pacific Islander (35% Samoan, 30% American Samoan, and 35% Tongan). Ninety-eight percent of respondents were overweight/obese, and 45% of households were food insecure. Less than half of respondents were born in the United States, and 28% reported "poor" or "fair" English proficiency. Those with higher body mass indexes were more likely to score lower on internal locus of control and self-efficacy for healthy eating and were motivated to lose weight to feel in control of their health. Focus group results revealed that members of the Samoan/Tongan communities are "underserved" and experience a lack of culturally relevant programs to address obesity and chronic disease. Several barriers to healthier lifestyles were identified including adaptation of traditional recipes made in the United States (ie, to be less healthy), role of stress, cultural values (eg, preference for larger body size), and lack of awareness about healthy lifestyles. The church was identified as a resource that could be leveraged further to positively impact health outcomes., Conclusions: Results demonstrate possible ways to tailor the DPP for US-based Samoan/Tongan populations by harnessing cultural traditions and addressing existing barriers and psychosocial constructs., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose: To investigate whether demographic, clinical, or psychosocial factors act as moderators of change in medication adherence in the Support, Educate, Empower (SEE) program., Design: Prospective, single-arm pilot study with a pre-post design., Participants: Patients with glaucoma aged ≥ 40 years and taking ≥ 1 glaucoma medication were recruited from the University of Michigan Kellogg Eye Center. Those who had electronically measured adherence ≤ 80% in the 3-month eligibility monitoring period were enrolled in the SEE program., Methods: Medication adherence was monitored electronically during the 7-month intervention and calculated as the percentage of doses taken correctly. Change in adherence at different points in the SEE program and cumulative change in adherence were modeled with linear regression, and baseline demographic, clinical, and psychosocial factors were investigated for significant associations., Main Outcome Measures: Demographic, clinical, and psychosocial variables associated with change in medication adherence in the SEE program., Results: Thirty-nine participants completed the SEE program. These participants were on average 63.9 years old (standard deviation [SD], 10.7 years), 56% (n = 22) were male, 44% (n = 17) were White, and 49% (n = 19) were Black. Medication adherence improved from an average of 59.9% (SD, 18.5%) at baseline to 83.6% (SD, 17.5%) after the final SEE session, for an increase of 23.7% (SD, 17.5%). Although participants with lower income (< $25 000 and $25 000-50 000 vs. >$50 000) had lower baseline adherence (48.4% and 64.1% vs. 70.4%), these individuals had greater increases in adherence during the first month of medication reminders (19.6% and 21.6% vs. 10.2%; P = 0.05 and P = 0.007, respectively). Participants taking fewer glaucoma medications also had significantly greater increases in adherence with medication reminders (P < 0.001). Those with higher levels of glaucoma-related distress (GD) had lower baseline adherence and greater increases in adherence with glaucoma coaching (P = 0.06)., Conclusions: Patient-level factors associated with relatively greater improvements in medication adherence through the SEE Program included lower income, fewer glaucoma medications, and increased GD. These findings demonstrate that the SEE program can improve glaucoma self-management even among participants with social and psychological barriers to medication adherence., (Copyright © 2021 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Firearms are a leading cause of death among youth and young adults. Given community violence is an important correlate of youth firearm carriage, we evaluated: 1) If the association between perceived community violence and firearm carriage is stronger when perceived police bias is greater; and 2) If this moderated association differs by race. Cross-sectional data came from screening data for a longitudinal study of firearm behaviors among young adults seeking urban emergency department treatment between July 2017-June 2018 (N = 1264). We estimated Poisson regressions with robust error variance to evaluate associations between perceived community violence, police bias, race, and firearm carriage. Community violence was positively associated with firearm carriage (average marginal effect [AME]: 0.05; 95% Confidence Interval [CI]: 0.03, 0.07). We also found that the positive association between community violence and firearm carriage increased with higher perceptions of police bias (interaction p < 0.05). We did not find evidence of a three-way interaction by which the moderated association between violence exposure and firearm carriage by perceived police bias varied by race of the respondents. Our findings suggest that community-level strategies to reduce violence and police bias may be beneficial to decrease youth firearm carriage in socio-economically disadvantaged urban settings., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Background: Youth violence is a leading cause of adolescent mortality, underscoring the need to integrate evidence-based violence prevention programs into routine emergency department (ED) care., Objectives: To examine the translation of the SafERteens program into clinical care., Methods: Hospital staff provided input on implementation facilitators/barriers to inform toolkit development. Implementation was piloted in a four-arm effectiveness-implementation trial, with youth (ages 14-18 years) screening positive for past 3-month aggression randomized to either SafERteens (delivered remotely or in-person) or enhanced usual care (EUC; remote or in-person), with follow-up at post-test and 3 months. During maintenance, ED staff continued in-person SafERteens delivery and external facilitation was provided. Outcomes were measured using the RE-AIM implementation framework., Results: SafERteens completion rates were 77.6% (52/67) for remote and 49.1% (27/55) for in-person delivery. In addition to high acceptability ratings (e.g., helpfulness), post-test data demonstrated increased self-efficacy to avoid fighting among patients receiving remote (incidence rate ratio [IRR] 1.22, 95% confidence interval [CI] 1.09-1.36) and in-person (IRR 1.23, 95% CI 1.12-1.36) SafERteens, as well as decreased pro-violence attitudes among patients receiving remote (IRR 0.83, 95% CI 0.75-0.91) and in-person (IRR 0.87, 95% CI 0.77-0.99) SafERteens when compared with their respective EUC groups. At 3 months, youth receiving remote SafERteens reported less non-partner aggression (IRR 0.52, 95% CI 0.31-0.87, Cohen's d -0.39) and violence consequences (IRR 0.47, 95% CI 0.22-1.00, Cohen's d -0.49) compared with remote EUC; no differences were noted for in-person SafERteens delivery. Barriers to implementation maintenance included limited staff availability and a lack of reimbursement codes., Conclusions: Implementing behavioral interventions such as SafERteens into routine ED care is feasible using remote delivery. Policymakers should consider reimbursement for violence prevention services to sustain long-term implementation., (Copyright © 2021 Elsevier Inc. All rights reserved.)

Church-based stroke prevention programs for Hispanics are underutilized. The Stroke Health and Risk Education (SHARE) project, a multicomponent cluster-randomized trial, addressed key stroke risk factors among predominantly Mexican Americans in a Catholic Church setting. Process evaluation components (implementation, mechanisms of impact, and context) are described. Partner support promoted positive health behavior change. Motivational interviewing calls were perceived as helpful, however, barriers with telephone delivery were encountered. Intervention exposure was associated with theory constructs for targeted behaviors. We conclude that health behavior interventions to prevent stroke can be successfully implemented for Mexican Americans within a Catholic Church setting, with parish priest support., (© 2021. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Little information has been compiled across studies about existing interventions to mitigate issues of medical financial hardship, despite growing interest in health care delivery. The purpose of this qualitative systematic scoping review was to examine content and outcomes of interventions to address medical financial hardship. PRISMA guidelines were applied to present results using PubMed, Scopus, and CINAHL, published between January 1980 and August 2020. Additional studies were identified through reference lists of selected papers. Included studies focused on mitigating medical financial hardship from out-of-pocket (OOP) health care expenses as an intervention strategy with at least 1 evaluation component. Screening 2412 articles identified 339 articles for full-text review, 12 of which met inclusion criteria. Variation was found regarding targets and outcome measurement of intervention. Primary outcomes were in the following categories: financial outcomes (eg, OOP expenses), behavioral outcomes, psychosocial, health care utilization, and health status. No included studies reported significant reduction in OOP expenses, perceptions of financial burden/toxicity, or health status. However, changes were observed for behavioral outcomes (adherence to treatment, patient needs addressed), some psychosocial outcomes (mental health symptoms, perceived support, patient satisfaction), and care utilization such as routine health care. No patterns were observed in the achievement of outcomes across studies based on intensity of intervention. Few rigorous studies exist in this emerging field, and studies have not shown consistent positive effects. Future research should focus on conceptual clarity of the intervention, align outcome measurement and achieve consensus around outcomes, and employ rigorous study designs, measurement, and outcome follow-up.

Background: Vaccination against COVID-19 is an important public health strategy to address the ongoing pandemic. Examination of online search behavior related to COVID-19 vaccines can provide insights into the public's awareness, concerns, and interest regarding COVID-19 vaccination., Objective: The aim of this study is to describe online search behavior related to COVID-19 vaccines during the start of public vaccination efforts in the United States., Methods: We examined Google Trends data from January 1, 2021, through March 16, 2021, to determine the relative search volume for vaccine-related searches on the internet. We also examined search query log data for COVID-19 vaccine-related searches and identified 5 categories of searches: (1) general or other information, (2) vaccine availability, (3) vaccine manufacturer, (4) vaccine side-effects and safety, and (5) vaccine myths and conspiracy beliefs. In this paper, we report on the proportion and trends for these different categories of vaccine-related searches., Results: In the first quarter of 2021, the proportion of all web-based search queries related to COVID-19 vaccines increased from approximately 10% to nearly 50% of all COVID-19-related queries ( P <.001). A majority of COVID-19 vaccine queries addressed vaccine availability, and there was a particularly notable increase in the proportion of queries that included the name of a specific pharmacy (from 6% to 27%; P =.01). Queries related to vaccine safety and side-effects (<5% of total queries) or specific vaccine-related myths (<1% of total queries) were uncommon, and the relative frequency of both types of searches decreased during the study period., Conclusions: This study demonstrates an increase in online search behavior related to COVID-19 vaccination in early 2021 along with an increase in the proportion of searches related to vaccine availability at pharmacies. These findings are consistent with an increase in public interest and intention to get vaccinated during the initial phase of public COVID-19 vaccination efforts., Competing Interests: Conflicts of Interest: None declared., (©Lawrence An, Daniel M Russell, Rada Mihalcea, Elizabeth Bacon, Scott Huffman, Ken Resnicow. Originally published in JMIR Infodemiology (https://infodemiology.jmir.org), 12.11.2021.)

Background . The purpose of the current article is to demonstrate how formative process evaluation was used in a pilot study to optimize the design and implementation of two motivationally targeted community-based physical activity (PA) interventions for inactive African American women. Method . Fifteen African American women (M age: 41.6 years) were randomized to a challenge-focused program targeted toward high autonomous motivation or a rewards-focused program targeted toward low autonomous motivation. The challenge-focused program targeted enjoyment and valuation of PA and a team-based positive social climate through competitive intergroup activities and team-based goals, whereas the rewards-focused program targeted PA interest, competency, and partner-based social support through a walking program, individual-based goals with financial incentives, and partner-based action-plans. Results . Feedback from participants revealed high levels of acceptability of essential elements. Average weekly attendance exceeded the a priori goal of ≥75% of members in attendance each week. External systematic observation demonstrated that session content dose was ≥93% in both programs. Facilitator-level fidelity exceeded the a priori goal of averaging ≥3 on a 4-point scale for behavioral skills, communication, autonomy support, and session content. The process evaluation also revealed areas for improvement, including facilitator-level social support and behavioral skills at the group-level. Process data collected through FitBits revealed that participants were engaged in self-monitoring PA during the 6-week programs. Conclusions . The formative process evaluation demonstrated adequate levels of feasibility and acceptability and also provided key insights into adjustments needed before proceeding with implementing the motivationally targeted group-based programs in a larger randomized study.

Racial discrimination can lead to psychosocial problems for Black adolescents, including internalization (e.g., depression) and externalization (e.g., conduct problems). Black parents (N = 186; M age  = 42.9) of adolescents (ages 10-18) were assessed to investigate how parental worries and racial socialization competency (i.e., confidence, skills, and stress) contribute to the association between parental discrimination experiences and their adolescents' psychosocial problems. Mediation analyses indicated that the total direct models with discrimination, worries, and problems had good fit, and that the addition of worry mediated the discrimination-problems association. Furthermore, racial socialization competency moderated the association between worry and problems, wherein greater competency was associated with less impact of worry on problems. Findings illuminate potential intervention targets for buffering discrimination's influence on adolescents' psychosocial functioning., (© 2021 The Authors. Child Development © 2021 Society for Research in Child Development.)

Objective: To determine if Motivational Interviewing (MI) versus health education (HE) elicited different types of client language and whether these differences were associated with outcomes in a randomized clinical trial (RCT) for cessation induction among people who smoke with low motivation to quit. Methods: A secondary data analysis was conducted using data from the MI and HE arms of a trial in which people who smoke ( N = 202) with low desire to quit were randomly assigned to four sessions of MI, HE or brief advice. Mediation analyses examined two types of client language: change talk (CT) and a novel form of client speech called "learning talk" (LT). Outcomes were assessed at baseline, 3 and 6 months. Results: With HE as the reference group, MI resulted in greater CT ( OR = 3.0, 95% CI: 1.7-5.5) which was associated with better outcomes (average d = .34, SD = .13) and HE resulted in greater LT ( OR = .05, 95% CI: .02-.10) which was also associated with better outcomes (average d = .42, SD = .08). Indirect parallel mediation effects on quit attempts were significant for both MI-CT ( OR = 1.4, 95% CI: 1.1-1.7) and HE-LT ( OR = .4, 95% CI: .2-.7). Conclusions: MI and HE were both efficacious via different pathways to change, confirming the utility of MI in this RCT as well as highlighting the potential of HE based on the "5R's" for smoking cessation. These findings emphasize the value of exploring theorized mechanisms of action of interventions evaluated in RCTs. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Objectives: To evaluate motivations for firearm possession among urban young adults and determine if differences emerge between parents and non-parents, and to identify if storage practices differed according to motivation for firearm possession and parenting status., Methods: We used cross-sectional data among young adults seeking urban emergency department treatment at Hurley Medical Center between 2017 and 2018. Our analyses, completed in 2020, included 194 firearm-possessing young adults, 95 of whom were young parents., Results: Firearm-possessing parents were more likely to have a firearm for protection, than for any other motivation, compared with firearm-possessing non-parents (OR: 2.38, 95% CI 1.06 to 5.46). A significant interaction between parenting status and motivation for possession indicated the association between protective motivations and locked storage was significantly different between parents and non-parents, whereby there was a decreased odds of locked storage among non-parents who were motivated to possess a firearm for protection compared with any other motivation, but this association did not exist for parents (interaction OR=10.57, p<0.05)., Conclusion: Parental motivation for possessing a firearm most often lies in the desire to protect families. This motivation, however, does not necessitate unsafe storage., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2021. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Sleep is increasingly recognized as a vital part of health. Screen time has been linked to sleep quality in children. The purpose of this study was to analyze associations between screen time and sleep characteristics among low-income preschoolers., Methods: A total of 1,700 preschool-aged children participated in this study at 50 federally and state-funded preschool centers in Michigan. Baseline measurement for an ongoing longitudinal intervention trial was obtained for cross-sectional use. At baseline, parents reported the number of hours their child spent engaging in screen time on a typical week day and weekend. An aggregate measure of total screen time was created. Parents reported on the quality of their child's sleep, how often they were tired during the day, and whether they had difficulty falling asleep. A mixed model linear regression was created to analyze data., Results: Controlling for child's age, race, and parental income, children who engaged in more screen time were significantly more likely to have more trouble falling or staying asleep, be tired during the day, and had worse quality of sleep (P values = .004, .006 and .001, respectively). Spearman correlations of screen time, sleep variables and demographics show parents of Black children reported significantly higher weekly screen time than parents of non-Black children (r = 0.23, P < .001) and that tiredness was associated with Black race (r = 0.15, P < .001), Hispanic/Latino ethnicity (r = -0.14, P < .001), and parental education (r = 0.06, P = .016)., Conclusion: This report confirms prior associations between screen time and sleep reported in other pediatric populations. Further research is needed to confirm these results in other populations using more rigorous measures of screen time, sleep, and physical activity, as well as longitudinal assessments. Despite these limitations, findings suggest that interventions to help parents limit children's screen time and impact their sleep health merit investigation., (© 2021 John Wiley & Sons Ltd.)

Background: Women 50-65 years of age have the lowest cervical and colorectal cancer (CRC) screening rates among ages recommended for screening. The primary aim of this work is to determine how cancer risk perceptions and provider communication behaviors, in addition to known demographic factors, influence the uptake of both cervical and CRC screening or a single screen among women in southeast Michigan., Methods: Fourteen health services and communication behavior questions were adapted from the Health Information National Trends Survey (HINTS) and administered to a multiethnic sample of adults in southeast Michigan. The outcome variable was self-reported up-to-date cervical cancer and/or CRC screening as defined by the United States Preventive Services Task Force (USPSTF). Demographic and cancer risk/communication behavior responses of the four screening populations (both tests, one test, no tests) were analyzed with multinomial regression for all comparisons., Results: Of the 394 respondents, 54% were up to date for both cervical and CRC screening, 21% were up to date with only cervical cancer screening and 12% were up to date for only CRC screening. Of the 14 risk perception and communication behavior questions, only 'Did your primary care physician (PCP) involve you in the decisions about your health care as much as you wanted?' was significantly associated with women having both screens compared to only cervical cancer screening (aOR 1.67; 95% CI: 1.08, 2.57). The multivariate model showed age, and Middle East and North African (MENA) ethnicity and Black race, in addition to PCP-patient dyad decision-making to be associated with the cancer screenings women completed., Conclusions: Optimizing PCP-patient decision-making in health care may increase opportunities for both cervical cancer and CRC screening either in the office or by self-sampling. Understanding the effects of age and the different interventional strategies needed for MENA women compared to Black women will inform future intervention trials aimed to increase both cancer screenings., Funding: This work was supported by NIH through the Michigan Institute for Clinical and Health Research UL1TR002240 and by NCI through The University of Michigan Rogel Cancer Center P30CA046592-29-S4 grants., Competing Interests: DH Senior editor, eLife, MT, AA, NS, MP, KR No competing interests declared, (© 2021, Harper et al.)

Background: Southeast Michigan is home to the second largest Middle Eastern and North African (MENA) US population. There is increasing interest in understanding correlates of psychosocial outcomes and health behaviors in this growing population. One potentially important health correlate is ethnic identity (EI). This paper reports the development, validity, and initial correlates of a new measure of MENA identity named the MENA-IM., Methods: We used convenience sampling at locations frequented by individuals of MENA descent in southeast Michigan. We also measured EI centrality, religiosity, cultural mistrust, substance use, and health status to assess convergent and divergent validity. Exloratory and Confirmatory Factor Analysis identified three subscales, which were valid for both Arab and Chaldean respondents and were named (1) MENA cultural affiliation, (2) MENA media use, and (3) multicultural affiliation. We also created and tested a 20-item, single-factor version., Results: We obtained data from 378 adults, 73% of whom identified as Arab and 27% as Chaldean. MENA-IM scores were higher among older, lower-educated, lower-income, non-US born, and Arabic-speaking respondents. Arab respondents reported significantly higher scores than Chaldeans. MENA-IM scores were positively associated with EI centrality and religiosity. Higher MENA-IM scores were found among those not reporting use of marijuana, alcohol, and opiates. Higher MENA-IM scores were also found among those without a self-reported history of heart disease and among those with better mental health status., Discussion: The MENA-IM has strong psychometric properties and demonstrated initial evidence of convergent and discriminant validity. In general, values on the measure were associated with better psychosocial and health status. How the measure performs with MENA populations outside of Michigan and how it may relate to other health outcomes merit investigation., (© 2020. The Author(s).)

Objective: Our goal was to develop a scale to assess social distance attitudes related to COVID-19., Methods: We performed an online national survey of US adults (n = 1,074) to assess social distance attitudes, COVID-19 related beliefs and behaviors, and demographics. We assessed scale structure using confirmatory factor analysis and evaluated internal consistency and validity. We assessed association of scale factors with respondent characteristics., Results: Confirmatory factor analysis supported a hypothesized two-factor solution. Internal consistency was high for both positive (Alpha = 0.92) and negative (Alpha = 0.91) attitude factors. Analyses supported construct and predictive validity with expected associations between scale factors and perceived norms and behavior (e.g. trips out of the home). We found an interaction suggesting that holding highly negative attitudes reduced the effect of holding positive beliefs. Both attitude factors were related to age, gender, race/ethnicity, and political affiliation. Perceived COVID-19 risk (to others but not for self) and perceived severity were consistently associated with higher positive and lower negative attitudes., Conclusion: This COVID-19 Social Distance Attitude Scale contains positive and negative factors with high internal consistency and construct and predictive validity., Practice Implication: A greater understanding and ongoing assessment of COVID-19 social distance attitudes could inform policymakers, researchers, and clinicians who seek to promote protective social distance behaviors., Competing Interests: Declaration of Competing Interest The authors report no declarations of interest., (Copyright © 2020. Published by Elsevier B.V.)

Background: Face-to-face tobacco cessation has had limited reach and efficacy in Alaska Native (AN) communities. We describe our two-phased approach to develop content for Connecting Alaska Native People to Quit Smoking, a Facebook group intervention to reduce barriers to evidence-based smoking cessation treatment for AN people in Alaska., Methods: Phase 1 included semi-structured telephone interviews with 30 AN people who smoke and ten stakeholders. They provided feedback on existing content from the Centers for Disease Control and Prevention Tips campaign and AN digital stories. Phase 2 included an online survey with a new group of 40 AN smokers who provided feedback on existing content via a measure of perceived effectiveness and cultural relevance., Results: Phase I results revealed participants evaluated content based upon story strength, relevance to AN culture, emotional appeal, relatability to AN people, and favorite video. No single posting was rated highly across all themes. All perceived effectiveness (PE) and cultural relevance median scores fell between 3.5 and 4.4 (range 1-5). PE scores varied across participant demographic groups., Conclusions: Content embodying characteristics perceived to be most appealing, effective, and culturally relevant were selected for the private Facebook group content library with refinements made to incorporate images of AN people engaged in AN activities. PE scores indicate a need for a wide variety of content that moderators could pull from when conducting the intervention., Implications: Social media content targeting specific population sectors, such as American Indian/AN people for tobacco cessation needs to be culturally tailored. Our approach provides a model others can follow to determine what is appealing, relevant, and effective messaging., Clinical Trial Registration: NCT03645941., (© The Author(s) 2020. 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.)

Middle Eastern/North Africa (MENA) women are often not identified in cancer screening studies. The aim of this study was to determine the rates and predictors of cervical and colorectal cancer (CRC) screening for women 50-65 years of three race/ethnicities. White, black and MENA women of Southeast Michigan were surveyed once in 2019 for demographics, health care barriers, chronic diseases, and cancer screening updates using in-person, telephone, and online methods. Descriptive statistics and multivariate multinomial logistic regression were used to predict up-to-date colorectal cancer and cervical cancer screening. All analyses were adjusted by local population weights for comparability and generalizability. 394 women participated with 54% up-to-date on both screenings, 21% for cervical cancer screening alone, and 12% for CRC alone. Women more likely to be up-to-date for only cervical cancer screening compared to both cancer screens are younger (aOR 0.83 (95% CI 0.76, 0.92), are of MENA descent (7.97 (2.46, 25.76) and have no insurance (9.41 (1.07, 82.92). There are no predictors for women being up-to-date for CRC screening alone compared to both screens. Among women 50-65 years old, being up-to-date in cervical cancer screening is unrelated to being up-to-date for CRC screening. Compared to Healthy People 2020, there are significant gaps in cervical and CRC screening among women 50-65 years old of all races, but particularly among women of MENA descent who are even less likely to have CRC screening than cervical cancer screening., Competing Interests: The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (© 2021 The Authors. Published by Elsevier Inc.)

Substantial gaps remain in the evidence base for prenatal tobacco use interventions among Indigenous women. Using a cluster randomized controlled trial (RCT), the Healthy Pregnancies Project evaluated a community-level intervention for Alaska Native (AN) women in rural western Alaska. Sixteen villages were randomly assigned to usual care (control, n = 8 villages) or usual care plus a community-level intervention delivered by local AN "Native Sisters" ( n = 8 villages). Outcomes were tobacco use rate at delivery and at 2 and 6 months postpartum, with biochemical confirmation obtained at 6 months. The program had high reach, enrolling 73% of all eligible women screened. Of the 352 participants, 67% used tobacco at baseline. No significant differences emerged between study groups on follow-up in tobacco use rates. More intervention than control participants made a quit attempt at 2 months postpartum (70% vs. 51%, respectively, p = 0.012). Participants in both study groups reported the program helped to raise awareness of healthy pregnancies in the study villages. This trial supports the reach of a community-level intervention, but not its efficacy for reducing tobacco use during pregnancy or postpartum. Efforts to sustain early quit attempts appear warranted. The community involvement, and reported impact on raising awareness of the importance of healthy pregnancies, supports the value of the research program in this community.

Background: To increase vaccine acceptance, we created a Web-based the "Vaccines and Your Baby" intervention (VAYB) that provided new parents with vaccine information messages tailored to vaccine beliefs and values. We evaluated the effectiveness of the VAYB by comparing timely uptake of infant vaccines to an untailored version of the intervention (UT) or usual care intervention (UC) only., Methods: Between April 2016 and June 2019, we conducted a randomized clinical trial. Pregnant women and new parents were randomly assigned to the VAYB, UT, or UC arms. In the VAYB and UT arms, participants were exposed to interventions at 4 time points from pregnancy until their child was 15 months of age. The primary outcome was up-to-date status for recommended vaccines from birth to 200 days of age. A modified intent-to-treat analysis was conducted. Data were analyzed with logistic regression to generate odds ratios (ORs) and 95% confidence intervals (CIs)., Results: We enrolled 824 participants (276 VAYB, 274 UT, 274 UC), 143 (17.4%) of whom were lost to follow-up. The up-to-date rates in the VAYB, UT, and UC arms were 91.44%, 92.86%, and 92.31%, respectively. Infants in the VAYB arm were not more likely to be up to date than infants in the UC arm (OR = 0.89; 95% CI, 0.45-1.76) or in the UT arm (OR = 0.82; 95% CI, 0.42-1.63). The odds of being up to date did not differ between UT and UC arms (OR = 1.08; 95% CI, 0.54-2.18)., Conclusions: Delivering Web-based vaccine messages tailored to parents' vaccine attitudes and values did not positively impact the timely uptake of infant vaccines., Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose., (Copyright © 2020 by the American Academy of Pediatrics.)

Introduction: In general population samples, higher levels of stress and depression have been associated with increased prevalence of smoking in pregnancy. Little is known about the association of prenatal tobacco use, stress, and depression among American Indian or Alaska Native (AI/AN) women., Methods: The Healthy Pregnancies Project is a cluster-randomized controlled trial, evaluating a community-level intervention compared with usual care, for reducing tobacco use during pregnancy and postpartum among AN women in 16 villages in western Alaska. This cross-sectional study analyzed baseline data from enrolled pregnant women. Baseline measures included the self-reported, 7-day, point-prevalence current use of any tobacco, Perceived Stress Scale (PSS), and the Center for Epidemiological Studies-Depression (CES-D). Generalized estimating equations (GEE) analyses adjusted for village, participant age, and gestational age., Results: Participants (N = 352) were on average (SD) 25.8 (5.0) years of age and at 26.8 (9.8) weeks gestation. 66.5% were current tobacco users, of which 77% used Iqmik, a homemade form of smokeless tobacco. Compared with nonusers, tobacco users reported lower PSS score (p = .020) and less clinical levels of depression (CES-D ≥ 16) (18.1% vs. 9.3%, p = .21). Findings were not accounted for by nicotine dependence severity or self-reported tobacco use before pregnancy., Conclusions: In this sample of pregnant AN women, tobacco users report less stress and clinical levels of depression than nonusers. A potential challenge with tobacco treatment for pregnant AN women is to provide alternative ways of deescalating stress and affect management instead of using tobacco., Implications: This study contributes novel information on the association of tobacco use, perceived stress, and depression among Alaska Native women enrolled in a clinical trial to promote healthy pregnancies. Most prior studies addressing this topic were conducted among general population samples of pregnant women who smoked cigarettes. Little is known about these associations with prenatal smokeless tobacco, or among American Indian or Alaska Native women. The results are contrary to findings reported previously, because current tobacco use was associated with less stress and depression than nonuse. The study findings have implications for cessation treatment for this tobacco-use disparity group., (© The Author(s) 2019. 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.)

Importance: The novel coronavirus disease 2019 (COVID-19) pandemic has dramatically changed the US health care system, causing an influx of patients who require resources. Many oncologists are having challenging conversations with their patients about how the COVID-19 pandemic is affecting cancer care and may desire evidence-based communication guidance., Objectives: To identify the clinical scenarios that pose communication challenges, understand patient reactions to these scenarios, and develop a communication guide with sample responses., Design, Setting, and Participants: This qualitative study that was conducted at a single Midwestern academic medical center invited physicians to respond to a brief semistructured interview by email or telephone and then disseminated an anonymous online survey among patients with cancer. Oncology-specific, COVID-19-related clinical scenarios were identified by the physicians, and potential reactions to these scenarios were gleaned from the patient responses to the survey. Health communication experts were invited to participate in the iterative development of a communication guide, comprising 3 essential communication principles and strategies and informed by insights from physicians and patients. This study was conducted from March 25, 2020, to April 2, 2020., Interventions: Expert review, interviews, and surveys assessing challenging situations specific to cancer management during the COVID-19 pandemic., Main Outcomes and Measures: Oncology-specific, COVID-19-related clinical scenarios from physician interviews; responses to each scenario from patient surveys; and applicable communication principles from health communication expert literature review., Results: Of the 8 physicians who participated in interviews, 4 were men (50%) and 4 were women (50%). These physicians represented the following disciplines: internal medicine (n = 1), hematology/oncology (n = 2), radiation oncology (n = 3), and surgical oncology (n = 2). Their disease site specialization included cancers of the breast, head and neck, melanoma, and gastrointestinal and genitourinary tracts. A total of 48 patients with cancer completed the online survey; no demographic information was collected from the patients. The physicians identified 8 oncology-specific, COVID-19-related scenarios in which communication might be challenging: (1) worse outcomes from COVID-19, (2) delay in cancer screening, (3) delay in diagnostic workup, (4) delay in initiation of treatment, (5) offer of nonstandard treatment, (6) treatment breaks, (7) delay in follow-up imaging or care, and (8) inability to be admitted into the hospital for management. Potential patient reactions to each of these scenarios were compiled from survey responses. For most scenarios, patient reactions involved anger, fear, and anxiety (eg, "I'm scared"; "This isn't fair. I am upset."). These emotional patient responses informed the selection of the 3 general communication principles, which suggested language and strategies that physicians can use to respond to patients., Conclusions and Relevance: In this qualitative study, physicians and patients identified communication needs used by health communication experts to inform the development of a practical, evidence-based communication guide for oncology care during the COVID-19 pandemic.

Introduction: The transplant waiting list exceeds the number of organs available. One means of increasing the organ pool is to broaden potential donors to include those with chronic diseases., Research Questions: The study tested the effectiveness of using peer mentors to encourage individuals on dialysis to enroll on an organ donor registry., Design: Dialysis units were pair-matched by size and racial composition and then randomized to one of 2 interventions: meetings with a peer mentor (experimental intervention) or organ donation mailings (control). Peer mentors were trained to discuss organ donation with individuals on dialysis during in-person meetings at dialysis units. The primary outcome was verified registration in the state's donor registry., Results: After adjusting for age, gender, race, income, and education and accounting for correlation within the dialysis center, there was a significant intervention effect. Among individuals in the intervention group, the odds of enrolling (verified) on the donor registry were 2.52 times higher than those in the control group., Discussion: The use of peer mentors to discuss donating organs after death with individuals on dialysis can increase enrollment on a donor registry. Dispelling myths about chronic illness and donation can counter widely held misconceptions and help persons make an informed choice about end-of-life decisions and present an opportunity to increase the number of organs and tissues available for transplant.

Introduction: Primary care remains an underused venue for prevention and management of paediatric overweight and obesity. A prior trial demonstrated a significant impact of paediatrician/nurse practitioner (Ped/NP)-and registered dietitian (RD)-delivered motivational interviewing (MI) on child body mass index (BMI). The study described here will test the effectiveness of an enhanced version of this primary care-based MI counselling intervention on child BMI., Methods and Analysis: This cluster randomised effectiveness trial includes 24 Ped/NPs from 18 paediatric primary care practices that belong to the American Academy of Pediatrics (AAP) national Pediatric Research in Office Settings (PROS) practice-based research network. To date, practices have been randomised (nine to intervention and nine to usual care). Intervention Ped/NPs have been trained in MI, behavioural therapy, billing/coding for weight management and study procedures. Usual care Ped/NPs received training in billing/coding and study procedures only. Children 3- 11 years old with BMI > the 85th percentile were identified via electronic health records (EHRs). Parents from intervention practices have been recruited and enrolled. Over about 2 years, these parents are offered approximately 10 MI-based counselling sessions (about four in person sessions with their child's Ped/NP and up to six telephonic sessions with a trained RD). The primary outcome is change in child BMI (defined as per cent from median BMI for age and sex) over the study period. The primary comparison is between eligible children in intervention practices whose parents enrol in the study and all eligible children in usual care practices. Data sources will include EHRs, billing records, surveys and counselling call notes., Ethics and Dissemination: Institutional Review Board approval was obtained from the AAP. All Ped/NPs provided written informed consent, and intervention group parents provided consent and Health Insurance Portability and Accountability Act (HIPAA) authorisation. Findings will be disseminated through peer-reviewed publications, conference presentations and appropriate AAP channels., Trial Registration Number: NCT03177148; Pre-results., Competing Interests: Competing interests: None declared, (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Purpose: To assess the efficacy of the Support, Educate, Empower (SEE) glaucoma coaching program on medication adherence among glaucoma patients with low adherence., Design: Uncontrolled intervention study with a pre-post design., Participants: Glaucoma patients ≥ age 40, taking ≥1 medication, who self-reported poor adherence were recruited from the University of Michigan Kellogg Eye Center. Adherence was monitored electronically for a 3-month baseline period; participants with median adherence of ≤80% were enrolled in the SEE program., Methods: Participants' adherence was monitored electronically (AdhereTech, New York, NY) during the 7-month program. Adherence was calculated as the percentage of doses taken on time of those prescribed. The SEE program included (1) automated medication reminders, (2) 3 in-person counseling sessions with a glaucoma coach who had training in motivational interviewing (MI), and (3) 5 phone calls with the same coach for between-session support. The coach used a web-based tool to generate an education plan tailored to the patient's glaucoma diagnosis, test results, and ophthalmologist's recommendations (www.glaucomaeyeguide.org). The tool guided an MI-based conversation between coach and patient to identify barriers to adherence and possible solutions. Descriptive statistics were used to summarize baseline patient characteristics, and differences between those who did and did not complete the SEE program were tested with 2-sample t tests, chi-square tests, and Fisher exact tests. Adherence was compared before and after the SEE program with paired t tests., Main Outcome Measure: Change in electronically monitored medication adherence., Results: A total of 48 participants were enrolled. The participants were 54% male, 46% white, and on average 64 years of age (standard deviation [SD], 10.8 years), with an average worse-eye mean deviation (MD) of -7.9 dB (SD, 8.8 dB). Those completing the SEE program (n = 39) did not differ significantly from those who dropped out (n = 9) on gender, race, age, MD, or baseline adherence. Medication adherence improved from 59.9% at baseline to 81.3% (P < 0.0001) after completing the SEE program. Ninety-five percent of participants showed an improvement in adherence (mean relative improvement, 21.4%; SD, 16.5%; range, -3.2% to 74.4%; median, 20.1%). Fifty-nine percent of participants showed adherence of >80% on completing the SEE program., Conclusions: The SEE program participants showed clinically meaningful, statistically significant improvement in glaucoma medication adherence., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Purpose: To understand patients' qualitative experiences with the Support, Educate, Empower (SEE) personalized glaucoma coaching program, provide a richer understanding of the components of the intervention that were useful in eliciting behavior change, and understand how to improve the SEE Program., Design: A concurrent mixed-methods process analysis., Participants: Thirty-nine patients with a diagnosis of any kind of glaucoma or ocular hypertension who were aged ≥40 years, were taking ≥1 glaucoma medication, spoke English, self-administered their eye drops, and had poor glaucoma medication adherence (defined as taking ≤80% of prescribed medication doses assessed via electronic medication adherence monitors) who completed the 7-month SEE Program., Methods: All participants who completed the study were interviewed in-person using a semistructured interview guide after the intervention. Coders conducted qualitative analysis of transcribed interviews using Grounded Theory. Participants were then stratified into groups based on change in adherence, and thematic differences between groups were examined., Main Outcome Measures: Themes that emerged from interviews categorized by the number of participants who expressed a theme and the number of representative citations., Results: Participants expressed positive views toward the program overall (95%, n = 37/39). They perceived program components as working together to improve their medication adherence. Interactions with the glaucoma coach (38 participants, 184 citations), motivation to aid personal change (38 participants, 157 citations), personalized glaucoma education (38 participants, 149 citations), electronic reminders, and hearing their adherence score (37 participants, 90 citations) were most commonly cited by participants as helpful program elements contributing to improved adherence. Patients expressed a desire for personalized education to be a standard part of glaucoma care. Participants who demonstrated more improvement in adherence had a more trusting attitude toward the adherence score and a greater magnitude of perceived personal need to improve adherence., Conclusions: Participants reported a highly positive response to the in-person glaucoma education and motivational interviewing intervention used in conjunction with automated adherence reminders., (Copyright © 2020 American Academy of Ophthalmology. Published by Elsevier Inc. All rights reserved.)

Background: No effective cures for chemotherapy-induced peripheral neuropathy (CIPN) are known; however, exercise may be beneficial., Objective: The purpose of this review was to synthesize high-quality research publications reporting the effects of exercise on CIPN and related outcomes among people of all age groups who received neurotoxic chemotherapy., Methods: PubMed, CINAHL, Scopus, PsycINFO, and SPORTDiscus databases were searched first between May and November 2016 and then again in April 2019 for all clinical trials and meta-analyses. Subsequent hand-searching continued through April 2019. Potential scientific bias was rigorously evaluated, using the CONSORT (Consolidated Standards of Reporting Trials) guidelines., Results: Thirteen studies (7 randomized controlled trials, 6 quasi-experiments) were found that reported exercise effects in various adult CIPN populations (ie, mixed cancer types and stages, chemotherapy regimens and status, and CIPN presence and severity). No studies provided high-quality evidence; 2 studies provided moderate-quality evidence. Most studies (76.3%) evaluated combined aerobic, strength, and balance training interventions of varying dosages. The most commonly improved outcomes were CIPN, balance, and fitness. All 7 studies with an aerobic exercise component led to significant-most studies showing moderate to large-CIPN benefits., Conclusions: Few studies-none of high quality or in child/adolescent populations-have evaluated exercise effects on CIPN. The exercise interventions, dosages, and settings have been too heterogeneous to identify the most beneficial intervention for other CIPN-related outcomes. However, aerobic exercise may be a key component of exercise interventions for CIPN., Implications for Practice: Although promising, the empirical evidence is insufficient to definitively conclude that exercise interventions ameliorate CIPN.

Rates of cardiovascular disease and diabetes are rising in low- and middle-income countries (LMIC), but there is a dearth of research devoted to developing and evaluating chronic disease interventions in these settings, particularly in Africa. Lifestyle Africa is a novel, culturally adapted version of the Diabetes Prevention Program (DPP) being evaluated in an ongoing community-based cluster-randomized trial in an underresourced urban community in South Africa. The purpose of this study is to describe the adaptations and adaptation process used to develop the program and to report preliminary implementation findings from the first wave of groups (n = 11; 200 individuals) who participated in the intervention. The RE-AIM model and community advisory boards guided the adaptation process. The program was designed to be delivered by community health workers (CHWs) through video-assisted sessions and supplemented with text messages. Participants in the trial were overweight and obese members of existing chronic disease "support groups" served via CHWs. Implementation outcomes included completion of sessions, session attendance, fidelity of session delivery, and participant satisfaction. Results indicated that 10/11 intervention groups completed all 17 core sessions. Average attendance across all sessions and groups was 54% and the percentage who attended at least 75% of sessions across all groups was 35%. Fidelity monitoring indicated a mean of 84% of all required procedures were completed while overall communication skills were rated as "good" to "excellent". These preliminary results support the feasibility of culturally adapting the DPP for delivery by CHWs in underresourced settings in LMIC., (© Society of Behavioral Medicine 2020. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Acquiescence is often defined as the systematic selection of agreeable ("strongly agree") or affirmative ("yes") responses to survey items, regardless of item content or directionality. This definition implies that acquiescence is immune to item characteristics; however, the influence of item characteristics on acquiescence remains largely unexplored. We examined the influence of eight item characteristics on acquiescence in a telephone survey of 400 Latinos and non-Latino whites: qualified wording, mental comparisons, negated wording, unfamiliar terms, ambiguous wording, knowledge accessibility, item length, and polysyllabic wording. Negated and ambiguous wording was associated with reduced acquiescence for the full sample, as well as subsamples stratified by ethnicity and sociodemographic characteristics. This effect was strongest among younger, more educated, and non-Latino white respondents. No other item characteristics had a significant influence on respondent acquiescence. Findings from this study suggest that acquiescence may be affected by interactions between respondent and item characteristics.

Objective: Health disparities necessitate exploration of how race moderates response to smoking cessation treatment. Data from a randomized clinical trial of Motivational Interviewing (MI) for smoking cessation induction were used to explore differential treatment response between African American (AA) vs Non-Black (NB) smokers., Methods: Adult tobacco smokers (138 AA vs 66 NB) with low desire to quit were randomly assigned to four sessions of MI or health education (HE). Outcomes (e.g., quit attempts) were assessed 3- and 6-months., Results: There was evidence of a Race by Treatment interaction such that MI was less effective than HE in AA smokers. Mean Cohen's d for the interaction effect was -0.32 (95% CI [-0.44, -0.20]). However, the race interaction could be accounted for by controlling for baseline relationship status and communication preference (wants directive approach)., Conclusions: MI may be less effective for smoking cessation induction in AA vs NB smokers when compared to another active and more directive therapy. The differential response between races may be explained by psychosocial variables., Practice Implications: MI may not be an ideal choice for all African American smokers. Patients' relationship status and preference for a directive counseling approach might explain disparities in response to MI treatment., Competing Interests: Declaration of competing interest Catley, Goggin, and Resnicow received fees for providing Motivational Interviewing training. Catley received non-financial support from Pfizer., (Copyright © 2019 Elsevier B.V. All rights reserved.)