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BackgroundAcute coronary syndrome (ACS) is a leading cause of hospital admission in North America. Many patients with ACS experience challenges after discharge that impact their clinical outcomes and psychosocial well-being. SMS text messaging has the potential to provide support to patients during this postdischarge period. ObjectiveThis study pilot tested a 60-day SMS text messaging intervention (Txt2Prevent) for patients with ACS. The primary objective was to compare self-management domains between usual care and usual care plus Txt2Prevent. The secondary objectives were to compare medication adherence, health-related quality of life, self-efficacy, and health care resource use between groups. The third objective was to assess the feasibility of the study protocol and the acceptability of the intervention. MethodsThis was a randomized controlled trial with blinding of outcome assessors. We recruited 76 patients with ACS from St. Paul’s Hospital in Vancouver, Canada, and randomized them to 1 of 2 groups within 7 days of discharge. The Txt2Prevent program included automated 1-way SMS text messages about follow-up care, self-management, and healthy living. Data were collected during the index admission and at 60 days after randomization. The primary outcome was measured with the Health Education Impact Questionnaire (heiQ). Other outcomes included the EQ-5D-5L, EQ-5D-5L Visual Analog Scale, a modified Sullivan Cardiac Self-Efficacy Scale, and Morisky Medication Adherence Scale scores, and self-reported health care resource use. Analyses of covariance were used to test the effect of group assignment on follow-up scores (controlling for baseline) and were considered exploratory in nature. Feasibility was assessed with descriptive characteristics of the study protocol. Acceptability was assessed with 2 survey questions and semistructured interviews. ResultsThere were no statistically significant differences between the groups for the heiQ domains (adjusted mean difference [Txt2Prevent minus usual care] for each domain—Health-directed activity: –0.13, 95% CI –0.39 to 0.13, P=.31; Positive and active engagement in life: 0.03, 95% CI –0.19 to 0.25, P=.76; Emotional distress: 0.04, 95% CI –0.22 to 0.29, P=.77; Self-monitoring and insight: –0.14, 95% CI –0.33 to 0.05, P=.15; Constructive attitudes and approaches: –0.10, 95% CI –0.36 to 0.17, P=.47; Skill technique and acquisition: 0.05, 95% CI –0.18 to 0.27, P=.69; Social integration and support: –0.12, 95% CI –0.34 to 0.10, P=.27; and Health services navigation: –0.05, 95% CI –0.29 to 0.19, P=.69). For the secondary outcomes, there were no statistically significant differences in adjusted analyses except in 1 self-efficacy domain (Total plus), where the Txt2Prevent group had lower scores (mean difference –0.36, 95% CI –0.66 to –0.50, P=.03). The study protocol was feasible, but recruitment took longer than expected. Over 90% (29/31 [94%]) of participants reported they were satisfied with the program. ConclusionsThe Txt2Prevent study was feasible to implement; however, although exploratory, there were no differences between the 2 groups in adjusted analyses except for 1 self-efficacy domain. As the intervention appeared acceptable, there is potential in using SMS text messages in this context. The design of the intervention may need to be reconsidered to have more impact on outcome measures. Trial RegistrationClinicalTrials.gov NCT02336919; https://clinicaltrials.gov/ct2/show/NCT02336919 International Registered Report Identifier (IRRID)RR2-10.2196/resprot.6968

Background: Despite the suggested benefits of shared decision-making (SDM), its implementation in policy and practice has been slow and inconsistent. Use of complex adaptive systems (CAS) theory may provide understanding of how healthcare system factors influence implementation of SDM. Methods: Using the example of choice of mode of birth after a previous caesarean section, in-depth, semi-structured interviews were conducted with patients, providers, and decision makers in British Columbia, Canada, to explore the system characteristics and processes that influence implementation of SDM. Implementation and knowledge translation principles guided study design, and constructionist grounded theory informed iterative data collection and analysis. Findings: Analysis of interviews (n=58) revealed that patients formed early preferences for mode of delivery (after the primary caesarean) through careful deliberation of social risks and benefits. Physicians acted as information providers of clinical risks and benefits, while decision makers revealed concerns related to liability and patient safety. These concerns stemmed from perceptions of limited access to surgical resources, which had resulted from budget constraints. Discussion and conclusions: To facilitate the effective implementation of SDM in policy and practice it may be critical to initiate SDM once patients become aware of their healthcare options, assist patients to address the social risks that influence their preferences, manage perceptions of risk related to patient safety and litigation among physicians, and enhance access to healthcare resources.

This study was undertaken to examine gender differences in the perception of social constraints against smoking and to explore the role of other sociodemographic and smoking factors that influence the perception of social pressure. Baseline data from the 20 U.S. sites in the National Cancer Institute's Community Intervention Trial for Smoking Cessation (COMMIT) were analyzed. We found that women were less likely than men to be heavy smokers and to report that smoking had affected their health, but more likely to report behavior indicating physiological addiction (timing of first cigarette). At all smoking levels, women were about twice as likely as men to report feeling pressure to quit, after adjusting for education, income, ethnic group, age, and other factors. The source of pressure, however, was different: more women report pressure from their children, whereas more men report pressure from friends and coworkers. Women were equally likely as men to make quit attempts, after adjusting for other factors, but were less likely to remain abstinent for at least 10 days. Women, regardless of education, ethnicity, and age, reported a greater tendency to ask permission before smoking in non-restricted public places. College-educated men were less likely than men without college education to smoke without asking in non-restricted places, but education did not influence whether women asked permission. For both sexes, smoking level and nicotine dependence were significant predictors of lighting up without asking in public places, after adjustment for other variables. We discuss these findings and their implications for the gender gap in smoking cessation and women's conflicting pressures to stop/continue smoking. Tobacco control efforts are discussed within the context of gender differences in social norms, roles, socialization, and communication cultures. Key words - smoking cessation, gender

Objective To examine the relationship of dietary change to weight change in women who quit smoking and remained abstinent for 1 year. Methods For 1 year, 582 women participating in smoking cessation classes were studied. Weight, diet, and physical activity were measured at baseline and at 1, 6, and 12 months after smoking cessation. Multivariate regression models were used to predict 1-year weight change for the 139 women who remained abstinent. Results Women gained, on average, 9.9 lb over a 1-year period while increasing their intake of energy for 1 and 6 months but returning to baseline levels by 1 year. Sucrose, total carbohydrate, and fat intake increased significantly for the first month; fat and total carbohydrate intake remained at an increased level for 6 months. In unadjusted analyses, older women and those who smoked more cigarettes gained more weight than younger women and lighter smokers; lighter and heavier women gained more weight than women of intermediate weight. In adjusted analyses, age remained a significant factor and number of cigarettes remained of borderline significance. Change in energy intake was predictive of weight change only in women with the highest energy intake at baseline. Applications Dietitians should acknowledge that most women who quit smoking gain weight in the short term. Although many women increase their energy intake, change in energy level is only one factor in weight change. Over the long term, women with high baseline intakes appear to be able to affect their weight change by reducing their energy intake., Cigarette smokers who quit smoking live longer than those who continue to smoke, because quitting reduces the risk of lung cancer, heart disease, stroke, and other smoking-related diseases (1). Yet [...]

Objectives. This study was undertaken to explore smoking patterns and attitudes that influence smoking cessation and relapse among African Americans. Methods. Baseline data from eight Community Intervention Trial for Smoking Cessation (COMMIT) sites were analyzed. Results. Compared with Whites, African Americans who smoke less than 25 cigarettes per day were 1.6 times more likely to smoke within 10 minutes of awakening (a behavioral indicator of nicotine dependence), adjusting for education, age, and gender (OR= 1.2 for heavier smokers). African Americans reported a stronger desire to quit smoking and reported serious quit attempts in the past year. African Americans favored tobacco restrictions they were 1.8 times more likely than Whites to view smoking as a serious community problem, 1.7 times more likely to favor restrictions on cigarette vending machines, and 2.1 times more likely to prohibit smoking in their car). African Americans were lighter/moderate, menthol smokers. Conclusions. African Americans find smoking socially unacceptable and are strongly motivated to quit, but their 'wake-up' smoking may indicate high nicotine dependence, making abstinence difficult even for lighter smokers. (Am J Public Health. 1993;83:220-226), African-Americans appear to find smoking socially unacceptable but they may have more trouble quitting than whites. A survey of 11,968 American smokers found several differences in smoking patterns and attitudes between African-Americans and non-Hispanic whites. African-Americans were more likely to begin smoking at a later age. Eighty-two percent of African-American smokers smoked fewer than 25 a day compared with 58.8% of whites. Significantly more African-Americans than whites attempted to quit smoking in the previous year. However, of people who smoked fewer than 25 cigarettes per day, African Americans were 1.6 times more likely to smoke within 10 minutes of waking up, an indicator of severe dependency. African Americans were 1.8 times more likely than whites to think of smoking as a serious public health problem, 1.7 times more likely to approve of restrictions on cigarette vending machines and more than twice as likely to forbid smoking in their car.

Abstract Background The presence and influence of nongovernmental organizations (NGOs) in the landscape of global health and development have dramatically increased over the past several decades. The distribution of NGO activity and the ways in which contextual factors influence the distribution of NGO activity across geographies merit study. This paper explores the distribution of NGO activity, using Bolivia as a case study, and identifies local factors that are related to the distribution of NGO activity across municipalities in Bolivia. Methods The research question is addressed using a geographic information system (GIS) and multiple regression analyses of count data. We used count data of the total number of NGO projects across Bolivian municipalities to measure NGO activity both in general and in the health sector specifically and national census data for explanatory variables of interest. Results This study provides one of the first empirical analyses exploring factors related to the distribution of NGO activity at the national scale. Our analyses show that NGO activity in Bolivia, both in general and health-sector specific, is distributed unevenly across the country. Results indicate that NGO activity is related to population size, extent of urbanization, size of the indigenous population, and health system coverage. Results for NGO activity in general and health-sector specific NGO activity were similar. Conclusions The uneven distribution of NGO activity may suggest a lack of co-ordination among NGOs working in Bolivia as well as a lack of co-ordination among NGO funders. Co-ordination of NGO activity is most needed in regions characterized by high NGO activity in order to avoid duplication of services and programmes and inefficient use of limited resources. Our findings also indicate that neither general nor health specific NGO activity is related to population need, when defined as population health status or education level or poverty levels. Considering these results we discuss broader implications for global health and development and make several recommendations relevant for development and health practice and research.

Reviews trends in the use of alcohol, tobacco, and marijuana among high school seniors. Previous and current prevention efforts are highlighted and promising prevention approaches identified. (CH)