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Preventive interventions are critical to improving health equity among American Indian (AI) populations, yet interventions that promote physical activity (PA) among AI populations are scarce. This research addresses the research-to-practice gap by informing the adaption and implementation process of evidence-based interventions (EBIs) among rural AI older adults. We used a community-based approach and an Indigenous-focused adaptation theoretical framework. Qualitative, semi-structured interviews elicited detailed information on preferences for PA intervention among rural AI older adults. We applied a collaborative directed content analysis strategy, and established trustworthiness and relevance using an inter-rater reliability process and member checking. We conducted 21 interviews, all participants identified as AI, the mean age was 66 years (SD = 7.6), and 57% were female. Themes characterized contextual and cultural intervention considerations for adapting and implementing evidence-based PA interventions in rural AI older adults. Key findings included an emphasis on social and community interaction, strategies for targeted engagement, preference for group format, pairing PA sessions with shared meals, and inclusiveness in the PA intervention across ability levels and age groups. This study identified opportunities for adaptation of PA-focused EBIs among rural AI older adults. Findings can be applied to support the adaptation and implementation of effective and relevant PA-focused preventive interventions among this population which is at high risk for chronic disease and health disparities.

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).

American Indian (AI) older adults experience pronounced health disparities and demonstrate one of the lowest levels of physical activity (PA) among racial and ethnic groups. Nearly half of AI older adults live in rural areas, indicating distinct challenges to participation in PA. Research to identify factors influencing PA in this population is missing from the literature, yet is critical to informing culturally relevant PA intervention development and implementation. The purpose was to identify barriers to and facilitators of PA among rural AI older adults using the ecological model and qualitative methods. A community-based approach was used to conduct semi-structured interviews with rural AI older adults. Interview questions were based on a multi-level ecological model. Content analysis was performed, using an iterative coding process to identify findings. The mean age of participants (n = 21) was 66 years. Barriers to and facilitators of PA were identified across ecological model levels. Barriers included factors such as caregiving and community responsibilities, lack of acceptable areas for walking, and overall lack of community-level support for older adult health. Facilitators included a personal connection to the land and ancestors through PA, multigenerational participation, and supportive tribal policies. This study addressed a gap in the literature by identifying barriers to and facilitators of PA among rural AI older adults, which can inform PA intervention development. With barriers and facilitators identified by AI older adults themselves, the voices of those directly affected are uplifted to shape efforts toward addressing longstanding health disparities through relevant public health interventions.

INTRODUCTION. Stress and depressive symptoms have been linked to a reduced likelihood of sustaining smoking cessation. Because stress and depressive symptoms may negatively affect motivation to quit, stress and depression may also be important for whether or not smokers make a quit attempt. OBJECTIVE. To examine the relationship between perceived stress and depressive symptoms and initiating a quit attempt in a smoking cessation induction trial. METHODS. We conducted a secondary analysis of existing data from a randomized clinical trial (N=255) comparing motivational interviewing to health education and brief advice for smoking cessation induction in smokers with low motivation to quit. RESULTS. We observed positive associations between baseline predictors and quit attempts at week 12 (r=0.192, p

BACKGROUND: Describing lessons learned from using a community-based participatory research (CBPR) approach to conduct school-based child health research in a tribal community is an important contribution to the literature. OBJECTIVES: To identify how CBPR principles shaped the process of conducting a school-based child health intervention, and to describe lessons learned. METHODS: The study evaluates how CBPR principles guided a mixed-methods, school-based child health intervention to increase physical activity (PA). RESULTS: Nine key lessons are identified, associated with CBPR principles. CONCLUSIONS: This information can help researchers understand how to successfully navigate the challenges and opportunities of conducting CBPR-guided research in the context of a small, short-term project, including leadership turnover, multiple Institutional Review Board (IRB)s, and study design approaches amidst schools policy changes. Collectively, understanding the lessons learned through the perspective of CBPR principles may help others conduct meaningful research with schools and children in tribal communities.

Unplanned pregnancies lead to adverse health outcomes and contribute to economic burdens. A lack of continuity and consistency in immediate postpartum care may be a contributor. The most frequent postpartum medical encounters occur with the child’s pediatric health care provider, which represents an opportunity to discuss postpartum contraception. Therefore, our objective was to evaluate postpartum family planning knowledge and behavior in women, and to assess the potential acceptability of a pediatrician-delivered intervention to improve knowledge of and convenient access to contraception among postpartum women. This was a non-interventional pilot study that employed survey and interview methodology. Women attending pediatric visits for their newborn or infant (N = 346) were surveyed; 35 were interviewed. On average, respondents were 27 years old (SD = 6), 6 months postpartum (SD = 5), and resumed sex 8 weeks after delivery (SD = 6). Of those who had resumed sex, 68% were not using contraception at the time. However, only 18% of survey respondents wanted to have another child. Few exhibited accurate knowledge of birth spacing or long acting reversible contraception. Most interviewees (86%) supported the idea of pediatricians providing contraceptive counseling. Concerns identified included whether it was “allowable” and pediatrician’s lack of knowledge of complex maternal health histories. This study highlights a gap between contraceptive need and provision in postpartum women. However, the findings suggest women’s willingness to engage in conversations with their child’s pediatrician about family planning. Future research should assess the feasibility and impact of integrating postpartum counseling into pediatric visits.

The community readiness model (CRM) is a stage-matched assessment protocol to assess community readiness to address a public health issue. To identify appropriate, culturally sensitive, and community-specific intervention strategies for preventing obesity in children, researchers, and community members formed a partnership to address childhood obesity within one American Indian Reservation. The CRM guided 30 interviews in five communities to direct the team’s efforts in addressing obesity among children residing on the reservation. Interviews were scored across six dimensions on an anchored scale of one through nine; scores were then averaged to determine an overall readiness score for each community. A thematic analysis of interview responses aided in interpretation of the readiness scores and identified areas for prevention planning and intervention development. The overall community readiness score for the communities was 2.9 (SD = 0.5), which falls between 2 (denial/resistance) and 3 (vague awareness) on the anchored rating scale. The thematic analysis resulted in a hierarchal classification scheme with six broad themes that corresponded to the CRM dimensions and 13 sub-themes. The low readiness scores directed the team to implement corresponding strategies to increase awareness, while the thematic analysis suggested that action-based approaches might also be appropriate. The narrow range of scores suggest that community-wide assessments may be sufficient unless specific information is needed for each region of the community. The CRM may be an effective way to assess community readiness to address childhood obesity on an American Indian Reservation.

Objective:This study investigated the feasibility of delivering health-related short text messages to parents with the goal of reducing obesity risk among their children aged 3–5 years.Design:Quasi-experimental design involving one experimental group of 17 parents.Setting:Rural American Indian reservation.Methods:During the 5-week intervention period, parents received 3 topic-related text messages each week for a total of 15 messages. The topics focused on included nutrition, physical activity (PA), sleep, consumption of sugary beverages, TV viewing and screen time. Outcomes included assessments of feasibility including retention rates; delivery, receipt and response to text messages; and programme satisfaction. Pre- to posttest changes in parent knowledge of health behaviours associated with childhood obesity and parent report of these health behaviours in their child were also assessed.Results:A total of 100% (17/17) of the participants completed the study and final assessments. All texts ( n = 289) sent to participants were successfully delivered. Of the 85 texts that requested a response, parents responded to 91% (78/85) by answering the question. All participants reported they found the texts easy to understand. A total of 94% (16/17) of participants reported enjoying the frequency with which they received messages. At the end of the study, parents reported improved overall child health behaviours that approached statistical significance ( p = .051) and parents reported significantly improved behaviours related to PA and sleep ( p = .046). No significant differences were found for changes in parent knowledge.Conclusion:Findings suggest it is feasible to deliver a text messaging-based childhood obesity prevention intervention to parents of young children living on a rural American Indian reservation. Text messages were appreciated by parents and may influence child health behaviours associated with childhood obesity.

Introduction. Kansas falls consistently below average for adolescentvaccination of meningococcal (MCV), human papillomavirus(HPV), and influenza. Methods. For this study, the members of Kansas Chapter of theAmerican Academy of Pediatrics were emailed a confidential electronicsurvey soliciting their impressions of vaccination in theirpractice. Results. Of 137 providers emailed, 61 (45%) completed the survey.Thirteen providers were excluded as they did not see/vaccinate adolescentsor did not complete the survey. Tetanus, diphtheria, pertussis(Tdap), and MCV vaccines were most commonly up to date with31 (65%) and 20 (42%) respondents reporting greater than 90%immunization rates, respectively. HPV (n = 42, 89%) and influenza(n = 40, 83%) vaccines had refusal rates greater than 25% in mostclinics. Most practices (n = 44, 92%) used internal electronic medicalrecords to track vaccinations, although 29 practices (60%) utilizedthe state immunization information system. Providers requestedvaccine-specific patient education tools, positive media coverage,staffing support, and best-practices workshops to support vaccinationefforts. Conclusion. Kansas providers may not be optimizing availableresources to enhance these rates, such as Web IZ tracking and immunizationreminders. Patient education supplies, specific to HPV andInfluenza vaccination, potentially could increase vaccination rates.KS J Med 2017;10(4):84-87.

Introduction. The purpose of this study was to explore healthcare provider training, comfort, and provision of internet safety counseling. Prior research has demonstrated increased parental concern regarding the pervasive access to the internet by children, including the potential impacts of risky internet behavior and adverse media exposure. Methods. A self-reported survey was provided to a convenience sample of 31 healthcare providers during a mental health training seminar. Responses were analyzed using descriptive statistics. Results. Internet safety counseling, especially regarding risky online behavior, was not a focal point of provider-patient interaction in the sample population. This finding was reinforced with more than half of the respondents indicating that they infrequently or never provide internet safety counseling (n = 17, 56%). While research has placed an emphasis on the importance of discussing the risks of exposure to violence, drugs, and sexually explicit media online, this study found that the topics most often discussed were setting time limits (77%), limiting access to media devices (67%), and supervising internet use (50%). This may be due in part to the fact that most respondents (n = 17, 57%) reported never receiving training on internet safety counseling. Conclusions. Overall, significant deficits were identified in internet safety counseling training for professionals and provision of education for families. These finding were inconsistent with the American Academy of Pediatrics recommendations around media use counseling and a point of urgent concern given the increasing time spent on media devices, particularly during the COVID pandemic.

Background and Objectives Physical activity (PA) is a powerful protective factor known to reduce risk for chronic conditions across the life span. PA levels are lower among American Indians and Alaska Natives (AIANs) when compared with other racial/ethnic groups and decrease with age. This evidence justifies a synthesis of current intervention research to increase PA levels among AIANs. This systematic review examines completed interventions to increase PA among AIAN older adults and considers recommended practices for research with Indigenous communities. Research Design and Methods The systematic review was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic review protocols and reporting guidelines. Three electronic databases, PubMed, Web of Science, and PsycINFO, were searched for academic literature. Trials investigating interventions to increase PA among AIAN adults older than 50 years were eligible. The Quality Assessment Tool for Quantitative Studies was used to evaluate the quality of evidence. Results Three published trials were identified, including one group-level, clinic-based and two individual-level, home-based interventions. All were 6 weeks in duration, took place in urban areas, and used self-report PA measures. Findings indicated an overall increase in PA levels, improved PA-related outcomes, and improved psychosocial health among participants. None described community-engaged or culture-centered research strategies. Discussion and Implications The narrow yet promising evidence represents a need for expanded research and a call to action for using culture-centered strategies. An advanced understanding of cultural and contextual aspects of PA may produce more impactful interventions, supporting health and mobility across the life span.

Background Executive function (EF) is considered an important mediator of health outcomes. It is hypothesized that those with better EF are more likely to succeed in turning their intentions into actual health behaviors. Prior studies indicate EF is associated with smoking cessation. Experimental and longitudinal studies, however, have yielded mixed results. Few studies have examined whether EF predicts post-treatment smoking behavior. Fewer still have done so prospectively in a large trial. We sought to determine if EF predicts quit attempts and cessation among community smokers in a large randomized trial evaluating the efficacy of motivational interventions for encouraging cessation. Methods Participants (N = 255) completed a baseline assessment that included a cognitive battery to assess EF (Oral Trail Making Test B, Stroop, Controlled Oral Word Association Test). Participants were then randomized to 4 sessions of Motivational Interviewing or Health Education or one session of Brief Advice to quit. Quit attempts and cessation were assessed at weeks 12 and 26. Results In regression analyses, none of the EF measures were statistically significant predictors of quit attempts or cessation (all ps > 0.20). Conclusions Our data did not support models of health behavior that emphasize EF as a mediator of health outcomes. Methodological shortcomings weaken the existing support for an association between EF and smoking behavior. We suggest methodological improvements that could help move this potentially important area of research forward.

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.

Introduction Despite limitations in evidence, the current Clinical Practice Guideline advocates Motivational Interviewing for smokers not ready to quit. This study evaluated the efficacy of Motivational Interviewing for inducing cessation-related behaviors among smokers with low motivation to quit. Design Randomized clinical trial. Setting/participants Two-hundred fifty-five daily smokers reporting low desire to quit smoking were recruited from an urban community during 2010–2011 and randomly assigned to Motivational Interviewing, health education, or brief advice using a 2:2:1 allocation. Data were analyzed from 2012 to 2014. Intervention Four sessions of Motivational Interviewing utilized a patient-centered communication style that explored patients' own reasons for change. Four sessions of health education provided education related to smoking cessation while excluding elements characteristic of Motivational Interviewing. A single session of brief advice consisted of brief, personalized advice to quit. Main outcomes measures Self-reported quit attempts; smoking abstinence (biochemically verified); use of cessation pharmacotherapies; motivation; and confidence to quit were assessed at baseline and 3- and 6-month follow-ups. Results Unexpectedly, no significant differences emerged between groups in the proportion who made a quit attempt by 6-month follow-up (Motivational Interviewing, 52.0%; health education, 60.8%; brief advice, 45.1%; p =0.157). Health education had significantly higher biochemically verified abstinence rates at 6 months (7.8%) than brief advice (0.0%) (8% risk difference, 95% CI=3%, 13%, p =0.003), with the Motivational Interviewing group falling in between (2.9% abstinent, 3% risk difference, 95% CI=0%, 6%, p =0.079). Both Motivational Interviewing and health education groups showed greater increases in cessation medication use, motivation, and confidence to quit relative to brief advice (all p d =0.36, 95% CI=0.12, 0.60). Conclusions Although Motivational Interviewing was generally more efficacious than brief advice in inducing cessation behaviors, health education appeared the most efficacious. These results highlight the need to identify the contexts in which Motivational Interviewing may be most efficacious and question recommendations to use Motivational Interviewing rather than other less complex cessation induction interventions. Trial registration This study is registered at www.clinicaltrials.gov NCT01188018.

Background Children living in rural areas are at higher risk for obesity compared to urban children, and Native American (NA) children have the highest prevalence of overweight/obesity for all races combined. Out-of-school programs (OOSPs) are a promising setting to improve children’s health. Parents are important in supporting their child’s obesity-related behaviors, yet it remains unclear what combination and dose of parent engagement strategies is feasible and optimal. This study’s primary objective was to assess the feasibility of an OOSP and home-based obesity prevention intervention for rural NA and non-NA children. Methods This was an 11-week, two group, randomized feasibility study. Participants were children and their parents at one OOSP on a rural American Indian reservation. Children, ages 6–9, were randomized to receive the Generations Health (GH) intervention or comparison condition. The GH group received daily activities focused on physical activity (PA), nutrition, sleep, and reducing TV/screen time, and frequently engaged parents. The comparison group received usual OOSP activities. To assess intervention feasibility, we measured recruitment and participation rates and program satisfaction. We assessed pre- to posttest changes in body composition, PA and sleep patterns, dietary intake and Healthy Eating Index-2010 (HEI-2010) scores, TV/screen time, and nutrition knowledge. We report recruitment and participation rates as percentages and participants’ program satisfaction as means. Two-tailed paired t tests and 95% confidence intervals were used to detect changes in behavioral and health outcome variables. Results Forty-six children met age eligibility criteria; following screening, 52% (24/46) met the inclusion criteria and 96% (23/24) were randomized to the study. Overall, 91% of the children participated in the intervention and 100% participated in at least some of the posttest assessments. Parents reported high program satisfaction (mean rating of 4, on a 1–5 scale). Our outcome measure for child adiposity, zBMI, was reduced by 0.15 in the GH group, but increased by 0.13 in the comparison condition. Meaningful changes were evident for total kilocalories, HEI-2010 scores, PA, TV/screen time, and nutrition knowledge. Conclusions High recruitment, participation and program satisfaction and positive health and behavioral outcomes at 11 weeks provide encouraging indications of the feasibility and potential effectiveness of the intervention. Trial registration ISRCTN24274245

Background: Limited knee flexion and increased muscle co-contraction during jump landing are believed to diminish outcomes after anterior cruciate ligament (ACL) reconstruction. The efficacy of jump training to improve patients’ mechanical and neuromuscular deficits is understudied. Hypothesis: Jump training will improve functional, mechanical, and neuromuscular outcomes and higher repetition training augmented by body weight support will result in better retention of gains. Study Design: Randomized controlled trial; Level of evidence, 1. Methods: Thirty athletes (18 months after surgery) were screened, and 19 with mechanical deficits and limited clinical outcomes were enrolled in the trial. Testing included the International Knee Documentation Committee (IKDC) questionnaire, leg landing mechanics via motion analysis, knee joint effusion using a stroke test, and a surface electromyography–generated co-contraction index during a single-legged landing. Participants were randomly assigned to 1 of 2 groups: jump training with normal body weight (JTBW) and high-repetition jump training with body weight support (JTBWS). Knee effusion grading throughout training was used to assess joint tolerance. Changes in outcomes over time were analyzed with mixed-effects modeling. Immediate outcomes were compared with retention testing at 8 weeks after training by use of 2-way analyses of variance with effects of time and group. Results: Significant effects of time were found during the training phase for all outcome measures, but no effects of group or sex were found. IKDC score (pooled; mean ± SD) increased from 76 ± 12 to 87 ± 8 ( P < .001). Knee flexion during single-legged landing increased from 57° ± 11° to 73° ± 9° ( P < .001). Average co-contraction index decreased from 37 ± 15 to 19 ± 6 ( P < .001). All measures were retained over the retention period in both groups. The relative risk of knee effusion of the JTBW group versus the JTBWS group was 4.2 (95% CI, 2.25-7.71; P < .001). Conclusion: Jump training mitigated some risk factors for second injury and osteoarthritis in patients after ACL reconstruction. Training made lasting improvements in physical function measures as well as mechanical and neuromuscular coordination deficits. Higher repetitions used with body weight support did not improve retention but substantially reduced risk for effusion. Clinical Relevance: Jump training is an efficacious intervention for athletes with poor outcomes after ACL reconstruction, and training with body weight support lessens the risk for excessive joint stress during practice. Registration: NCT02148172 ( ClinicalTrials.gov identifier)

The aim of this study was to determine the effect of an 8-week recess intervention on physical activity levels in children attending elementary school on an American Indian reservation during fall 2013. Physical activity was measured with direct observation in three zones on the playground. Lines were painted on existing pavement in zone 1. Zone 2 had permanent playground equipment and was unchanged. Zone 3 contained fields where bi-weekly facilitators led activities and provided equipment. Pre- to post-changes during recess in sedentary, moderate physical activity, moderate-to-vigorous, and vigorous physical activities were compared within zones. Females physical activity increased in Zone 1 (moderate: 100% increase; moderate-to-vigorous: 83%; vigorous: 74%, p, Highlights • The intervention strategies were identified directly from the children. • The 8 week recess intervention split the playground into 3 zones. • In one of the zones we offer bi-weekly facilitator-led activities. • Females responded more to the intervention compared to males. • Simple and low-cost strategies were effective at increasing physical activity.

In an attempt to guide planning and optimize outcomes for population-specific smoking cessation efforts, the present study examined smoking prevalence and the demographic, clinical and psychosocial characteristics associated with smoking among a sample of Veterans Affairs primary care patients with probable major depression. Survey data were collected between 2003 and 2004 from 761 patients with probable major depression who attended one of 10 geographically dispersed VA primary care clinics. Current smoking prevalence was 39.8%. Relative to nonsmokers with probable major depression, bivariate comparisons revealed that current smokers had higher depression severity, drank more heavily, and were more likely to have comorbid PTSD. Smokers with probable major depression were also more likely than nonsmokers with probable major depression to have missed a health care appointment and to have missed medication doses in the previous 5months. Smokers were more amenable than non-smokers to depression treatment and diagnosis, and they reported more frequent visits to a mental health specialist and less social support. Alcohol abuse and low levels of social support were significant concurrent predictors of smoking status in controlled multivariable logistic regression. In conclusion, smoking prevalence was high among primary care patients with probable major depression, and these smokers reported a range of psychiatric and psychosocial characteristics with potential to complicate systems-level smoking cessation interventions.

Objectives: To explore factors influencing compliance with campus tobacco policies and strategies to increase compliance. Participants: Sixty tobacco smokers (April 2012). Methods: A 22-item intercept-interview with closed- and open-ended questions was conducted with smokers in adjacent compliant and noncompliant areas at 1 university with a 100% tobacco ban. Data were analyzed using descriptive statistics and content analysis. Results: Most reported that the smoking policy was not enforced. Noncompliant smokers had less knowledge of locations where tobacco use was permitted and were more likely to identify their smoking location as compliant and had knowingly violated the policy. Choice of location to smoke was related to convenience and a desire to follow the policy. Smokers recommended consequences for noncompliance and structures that accommodated smoking to increase adherence to the tobacco ban. Conclusions: Additional education, environmental, and contingency strategies are needed to increa...

The decisional balance (DB) procedure examines the pros and cons of behavior change and was considered a component in early formulations of Motivational Interviewing (MI). However, there is controversy and conflicting findings regarding the use of a DB exercise within the treatment of addictions and a need to clarify the role of DB as a component of MI.College tobacco smokers (N=82) with no intentions on quitting were randomly assigned to receive a single counseling session of either Motivational Interviewing using only the decisional balance component (MIDB), or health education around smoking cessation (HE). Assessments were obtained at baseline, immediately post-treatment, 1week, and 4weeks.Compared to HE, the MIDB sessions scored significantly higher on the Motivational Interviewing Treatment Integrity (MITI) scale (all standardized differences d1, p0.001). Unexpectedly, self-report Pros of smoking scores increased for MIDB but decreased for HE (MIDB vs HE standardized difference d=0.5; 95%CI 0.1 to 1.0, p=0.021). Both groups showed significant reductions in smoking rates and increases in motivation to quit, quit attempts, and self-reported abstinence, with no significant group differences. Changes in the Pros of smoking were correlated with MITI scores, but not with cessation outcomes. In contrast, increases in the Cons of smoking and therapeutic alliance were predictive of better cessation outcomes.The decisional balance exercise as formulated by earlier versions of MI may be counter-productive and cautions around its use are warranted. Instead, improved cessation outcomes appear associated with increasing perceived benefits of quitting and positive therapeutic alliance.

Background:Long-acting reversible contraception (LARC) is safe, effective, and recommended as first-line contraception for adolescents. Despite clear medical recommendations, the type and quality of Internet information regarding LARC for teenagers is unknown. Methods: Data were collected through web queries. Resulting websites were assessed for quality criteria and a priori content themes based on the leading medical societies’ recommendations for adolescent LARC. Results: Of the 238 websites evaluated, 77% made no recommendation of LARC for adolescent females. Of the 55 websites that did recommend LARC, only 40% specifically discussed its use in the adolescent population. Of note, 16% of websites recommending LARC discouraged their use in adolescents. Quality varied among LARC-discussing websites, ranging from 3 to 13 of the 15 criteria assessed. Discussion: Few websites offer up-to-date information regarding the use of LARC, and most fail to discuss LARC use at all. As LARC is highly effective in preventing unplanned pregnancies in adolescents, incomplete or inaccurate information on the Internet present a barrier to promoting its utilization in this at-risk population.

Smoking is the cause of over $100 billion in health care costs annually and accounts for approximately 443,000 deaths each year.1 Although the prevalence of smoking among African Americans is very similar to that of whites (currently 21% for both groups),2 African Americans experience a greater risk for tobacco-related morbidity and mortality.3,4 Studies also indicate that although African Americans have more quit attempts in a given year when compared to whites,5,6 they are much less likely to succeed in quitting.7,8 Although many biopsychosocial factors likely contribute to lower quitting success among African American smokers, one reason may be lower use of pharmacotherapy to aid in cessation attempts. Although pharmacotherapy has been shown to increase cessation success,9 there is evidence that pharmacotherapy is generally underused across all racial groups.10,11 However, studies of nicotine replacement use indicate that African Americans have even lower use rates (10–20%) when compared to those of whites (29–34%).6,10,12–18 In general, reasons for underuse include cost, lack of knowledge regarding efficacy,19 concerns about safety, and a perceived lack of access.20 However, whether similar or different reasons account for underuse by African Americans has not received much attention. One qualitative study examined several ethnic minorities’ attitudes and beliefs about pharmacotherapy.21 Results revealed that, similar to findings from previous studies of mostly white smokers, African American smokers (n = 26) were aware of the existence of cessation pharmacotherapy but were not knowledgeable regarding the specific benefits for cessation, such as reduced cravings and withdrawal symptoms. In addition, many smokers were skeptical of the effectiveness of all forms of cessation pharmacotherapy and were particularly reluctant to accept a medication in pill form. African American participants also reported believing that the side effects of all cessation aids would likely be worse than the health effects of smoking. The generalizability of these qualitative results to most African American smokers is unknown. Furthermore, Fu and colleagues21 did not determine which beliefs among those identified would be most significant in influencing participant decision making about the use of pharmacotherapy. Given the importance of increasing cessation among African American smokers and the dearth of research in this area, there is a need to extend this qualitative work to address these limitations.

Little is known regarding American Indian (AI) parental influence on children's diet and physical activity (PA), or if this influence is associated with childhood weight. We compared AI parents' diet, PA, and support for these behaviors with the child's body mass index. Scores for parental support of positive PA and diet were higher among parents of overweight/obese children. Parent PA and nutrition behaviors were in a similar, but not significant, direction with respect to child body mass index. Findings suggest that future research is needed to determine what parental, societal, or community variables influence AI children to engage in healthy eating and PA, especially if they are overweight or obese, and the age at which these variables would have the most impact on these behaviors.

This pilot study examined smoking reduction and cessation among college smokers with elevated depressive symptomatology participating in a group-based behavioral counseling, mood management, and motivational enhancement combined intervention (CBT).Fifty-eight smokers (smoked 6 days in the past 30) were randomized to 6 sessions of CBT (n = 29) or a nutrition-focused attention-matched control group (CG; n = 29).Relative to CG participants, significantly more CBT participants reduced smoking intensity by 50% (χ(2)[1, N = 58] = 4.86, p = .028) at end of treatment. Although CBT participants maintained smoking reductions at 3- and 6-month follow-up, group differences were no longer significant. No group differences in cessation emerged. Finally, participants in both groups evidenced increased motivation to reduce smoking at end of treatment (F[1, 44] = 11.717, p = .001, η(p)(2) = .207).Findings demonstrate the utility of this intervention for smoking reduction and maintenance of reductions over time among a population of college students with elevated depressive symptomatology.

Many who smoke in college do so infrequently and smoking conditions are not well understood. We examined smoking patterns among college fraternity and sorority members (N = 207) from a Midwestern university in three successive fall semesters in 2006-2008. Participants completed calendar-assisted retrospective assessments of 30-day smoking at up to five assessment points over 96 days. Overall smoking rates declined over the course of each semester and higher smoking on weekends was observed, with more variability among daily smokers. The most frequent categories of events to cue recall of smoking were socializing, work, and school. Findings can be used to target prevention efforts.

PurposeThe purpose of this study was to use a community-based participatory research (CBPR) approach to translate the original Diabetes Prevention Program (DPP) to be age and culturally specific for American Indian (AI) youth.MethodsTribally enrolled members on 2 Montana Indian reservations conducted focus groups and interviews to discuss community members’ perspectives of factors that encouraged or were barriers to healthy diet and exercise behaviors in AI youth. In total, 31 community members, aged 10 to 68 years old, participated in 4 focus groups and 14 individual interviews. Participants were self-identified as elder, cultural expert, tribal health worker, educator, parent/guardian, youth, or school food service worker. Researchers analyzed transcripts based on inductive methods of grounded theory.ResultsData analysis revealed translating the DPP to youth was contingent on the lessons incorporating cultural strategies for healthy behaviors in youth such as berry picking, gardening, horseback riding, and dancing; improving knowledge and access to healthy foods and physical activity for youth and their parents; having interactive, hands-on learning activities for healthy lifestyles in the DPP lessons; using a group format and tribal members to deliver the DPP lessons; and having tribal elders talk to youth about the importance of adopting healthy behaviors when they are young.ConclusionsA CBPR approach engaged community members to identify strategies inherent in their culture, tradition, and environment that could effectively translate the DPP to Montana Indian youth living in rural reservation communities.

Techniques to recruit and retain college fraternity and sorority members who reported past 30-day smoking into a cessation trial are described. Recruitment efforts included relationship-building, raffles, and screening survey administration during existing meetings. Surveys were administered to 76% (n = 3,276) of members in 30 chapters, 79% of eligible members agreed to participate, and 76% of those completed assessments and were enrolled in the trial (n = 452). The retention rate was 73%. Retention efforts included cash incentives, flexible scheduling, multiple reminders, chapter incentives, and use of chapter members as study personnel. Retention was not related to demographic, behavioral, or group characteristics. The strategies of partnership, convenience, and flexibility appear effective and may prove useful to investigators recruiting similar samples. © 2010 Wiley Periodicals, Inc. Res Nurs Health 33:144–155, 2010

Objectives: Data on effective strategies to enforce policies banning outdoor smoking are sparse. This study tested the effects of an enforcement package implemented on a college campus. Participants: Thirty-nine observers recorded compliance of 709 outside smokers. Methods: Smoking within 25 feet of buildings was noncompliant. The intervention included moving receptacles, marking the ground, improving signage, and distributing reinforcements and reminder cards. Results: The proportion of smokers complying with the ban was 33% during the baseline observation period, increased to 74% during the intervention week, and was at 54% during the follow-up. Differences across conditions was statistically significant (χ2 (2, N = 709) = 6.299, p

Methods assessing non-daily smoking are of concern because biochemical measures can not verify self-reports beyond 7 days. This study compares two self-reported smoking measures for non-daily smokers. A total of 389 college students, (48% female, 96% white, mean age of 19) smoking between 1 and 29 days out of the past 30, completed computer assessments in three cohorts with the order of administration of the measures counterbalanced. Values from the two measures were highly correlated. Comparisons of Timeline Follow-Back (TLFB) with the global questions for the total sample of non-daily smokers yielded statistically significant differences (p

Little is known about effective methods to recruit unmotivated smokers into cessation induction trials, the reasons unmotivated smokers agree to participate, and the impact of those reasons on study outcomes. A mixed-method approach was used to examine recruitment data from a randomized controlled cessation induction trial that enrolled 255 adult smokers with low motivation to quit. Over 15 months, 33% of smokers who inquired about the study were enrolled. Common recruitment methods included word-of-mouth, print advertisements and clinic referrals. Frequently mentioned reasons for participating included to: gain financial incentives (44.7%), learn about research or help others quit (43%), learn about smoking and risks (40%) and help with future quits (i.e. Quit Assistance, 23.9%). Separate regression models predicting study outcomes at 26 weeks indicated that smokers who said they participated for Quit Assistance reported higher motivation to quit (B 1.26) and were more likely to have made a quit attempt (OR 2.03) compared to those not mentioning this reason, when baseline characteristics were controlled. Understanding reasons for unmotivated smokers' interest in treatment can help practitioners and researchers design effective strategies to engage this population.

Social smoking is a newly identified phenomenon in the young adult population that is poorly understood. We investigated differences in social smoking (smoking most commonly while partying or socializing) and other smoking within a convenience sample of college smokers (n = 351) from a large midwestern university. Results revealed that 70% of 351 current (past 30-day) smokers reported social smoking. No significant difference was found in motivation to quit between smoking groups. However, a significant difference was found between groups in confidence to quit, the number of days smoked, and the number of cigarettes smoked on those days. More social smokers than expected did not perceive themselves as smokers. Logistic regression analysis revealed that lower physical and psychological dependence and higher social support scores predicted social smoking.

The purpose of this study was to examine whether counselor adherence to Motivational Interviewing (MI) principles was associated with more productive within-session client behavior in a smoking cessation trial for African American smokers. For these analyses 89 baseline counseling sessions of the trial were audiotaped and coded using the Motivational Interviewing Skill Code (MISC). Counselor adherence indicators included a global subjective rating of MI adherence and the frequency of MI-consistent and MI-inconsistent counselor behaviors described in the MISC. Indicators of productive client behaviors included global subjective ratings of within-session client functioning and counselor-client interaction, as well as the frequency of statements by the client favorable toward changing behavior (“change talk”) and resistant regarding changing behavior (“resist-change talk”). Results provided support for the principles of MI. Counselor adherence indexed by both the global subjective rating and MI-consistent behavior frequency was significantly positively associated with global ratings of within-session client functioning and counselor-client interaction, as well as more change talk.

About 28% of college students smoke tobacco, and many will continue smoking into adulthood. Although little is known about how to help college students quit smoking, 1 promising strategy is healthcare providers' advice. To estimate their life-time receipt of brief advice and to identify characteristics that predict who may receive that advice, 348 college students completed a survey about their smoking and related practices. Seventy-seven percent of the smokers (73% of the students) were asked about smoking. Of those smokers, 57% were advised to quit, 22% were given advice about quitting, 5% were helped with setting a quit date, and 4% were offered follow-up. Occasional smokers were less likely than daily smokers to be advised to quit. Although 36.2% of the smokers did not report their smoking accurately, smokers who were accurate were more likely to be advised to quit and to be given advice about quitting.

Objectives. Identification of individual characteristics that predict successful smoking cessation treatment has been limited to studies with mostly white participants. This study identifies factors that predict successful quitting among African-Americans participating in a smoking cessation trial. Methods. Twenty-one baseline variables were analyzed as potential predictors from a double-blind placebo-controlled, randomized trial that used bupropion SR for smoking cessation among 600 African-American smokers. Chi-square tests, two sample t tests, and multiple logistic regression procedures were employed to identify predictors of 7-day abstinence among the 535 participants who completed the 7-week medication phase. Results. Univariate predictors of cessation were receiving bupropion (P < 0.0001), not smoking menthol cigarettes (P = 0.0062), smoking after 30 min of waking (P < 0.0001), older age (P = 0.0085), smoking fewer cigarettes per day (P = 0.0038), and lower cotinine levels (P = 0.0002). Logistic regression identified three significant independent predictors. Participants who received bupropion treatment were more than twice as likely to quit smoking at the end of treatment compared to participants who received placebo (OR = 2.62; 95% CI = 1.77–3.88, P < 0.0001), while smoking within 30 min of waking (OR = 0.40; 95% CI = 0.25–0.62, P < 0.0001) and higher salivary cotinine levels at baseline (OR = 0.799; 95% CI = 0.629–0.922, P < 0.0001) reduced the likelihood of quitting. Conclusions. This is the first report identifying predictors of smoking cessation among African-Americans participating in a clinical trial. Results indicate that, aside from bupropion treatment, various indicators of addiction were the strongest predictors. While this is similar to findings among white smokers, thresholds of addiction may need to be adjusted for African-American smoking patterns. Additional studies focused on diverse populations are needed to improve treatment approaches and to identify population-specific factors that are important for treatment-matching approaches.

Objective To assess the effect of television viewing on subsequent change in body mass index (BMI=kg/m 2 ) percentiles (BMI%) in adolescence. Study design Data were drawn from the California Teen Longitudinal Survey of adolescents 12 to 17 years old with baseline assessment in 1993 and follow-up in 1996. Self-reported height and weight were used to calculate BMI and derive age-specific and sex-specific BMI%. Hours of television watched per day were obtained at baseline (BTV). The relations of BTV and BMI percentiles both at baseline and after 3 years were assessed with linear regression modeling. Results Of 2223 adolescents (52% male, 68% white), 5.85% (n=130) were overweight (BMI ≥95th percentile) at baseline and 5.40% (n=120) at follow-up. Mean BTV was 2.85 (SD, 1.98). In adjusted models, with each additional hour of BTV, the baseline BMI% increased by .9, and the follow-up BMI% increased by .47. Adolescents who watched more than 2 hours of television a day were twice as likely to be overweight at follow-up as adolescents who watched ≤2 hours. Conclusions Television viewing leads to a subsequent increase in BMI percentiles and overweight. Efforts to decrease overweight should consider interventions to reduce television time.

The motivational interviewing skills code (MISC) was used to review 86 audiotaped interactions between clinicians and patients participating in a smoking cessation intervention. Intraclass correlations (ICCs) were completed for two of the MISC elements: global evaluations and behavior counts. Results indicate 75% of the global ratings yielded ICCs in the good to excellent range, while only 44% of the behavior counts yielded this level of accuracy. Adherence scores were created to form overall ratings of clinician adherence to using motivational interviewing and 80% of these competence measures yielded ICCs in the good to excellent range. Specific recommendations regarding modifications for the MISC are suggested based on the data presented.

Although the overall prevalence of tobacco smoking in the United States is decreasing, the proportion of light smokers is increasing and is as high as 50% among some groups. There is growing evidence that light smokers experience significantly higher health risks compared to nonsmokers, and they are often unable to quit smoking on their own. The prevalence of light smoking differs among subpopulations in the US and is particularly common among adolescents, college students, pregnant women, and some ethnic minorities. Characteristics of light smokers in these subpopulations vary, as do the underlying reasons for smoking, barriers to cessation, and treatment issues. Unfortunately, the paucity of research to develop and test effective cessation aids is common across all groups of light smokers. Given the substantial portion of light smokers in these populations, development and dissemination of effective behavioral and pharmacological interventions for light smokers is likely to result in substantial smoking reduction rates in the general population.

Objectives. The purpose of the study was to determine associations between having a regular source of health care, advice from a physician to quit smoking, and smoking-related behaviors among African American smokers. Methods. A secondary analysis was conducted on data obtained from an intervention study with a posttest assessment of the effectiveness of smoking status as a vital sign. The setting was an adult walk-in clinic at a large inner-city hospital and 879 African American adult current smokers were examined. Results. Among African American smokers, there was an association between having a regular source of health care and planning to quit smoking within the next 30 days (OR = 1.46; 95% CI: 1.04–2.05), receiving physician advice to quit (OR = 1.46; 95% CI: 1.02–2.10), and smoking ≤10 cigarettes a day (OR = 1.42; 95% CI: 1.00–2.03). Conclusions. African American current smokers with a regular source of health care were further along the quitting process than those without a regular source of health care. Our findings indicate a potential benefit of complementing programs that increase physician cessation advice rates with policies that increase rates of health insurance and the likelihood that individuals have a regular source of health care.

ObjectiveMotivational interviewing (MI) is a widely used and promising treatment approach for aiding in smoking cessation. The present observational study adds to other recent research on why and when MI works by investigating a new potential mechanism: integrative complexity.SettingThe study took place in college fraternity and sorority chapters at one large midwestern university.ParticipantsResearchers transcribed MI counselling sessions from a previous randomised controlled trial focused on tobacco cessation among college students and subsequently scored clients’ and counsellors’ discussions across four counselling sessions for integrative complexity.InterventionsThis is an observational secondary analysis of a randomised controlled trial that tested the effectiveness of MI. We analysed the relationship between integrative complexity and success at quitting smoking in the trial.Primary and secondary outcome measuresSuccess in quitting smoking:Participants were categorised into two outcome groups (successful quitters vs failed attempters), created based on dichotomous outcomes on two standard variables: (1) self-reported attempts to quit and (2) number of days smoked via timeline follow-back assessment procedures that use key events in participants’ lives to prompt their recall of smoking.ResultsWe found (1) significantly higher complexity overall for participants who tried to quit but failed compared with successful quitters (standardised β=0.36, pLCI=0.16, (Upper Confidence Interval)UCI=0.47) and (2) the predictive effect of complexity on outcome remains when controlling for standard motivational and demographic variables (partialr(102)=−0.23, p=0.022).ConclusionsTaken together, these results suggest that cognitive complexity is uniquely associated with successful quitting in MI controlled trials, and thus may be an important variable to more fully explore during treatment.

Health risk perception in smoking behavior was prospectively evaluated in a cluster-randomized trial for smoking cessation in Greek college students. Perceived Vulnerability (PV), Precaution Effectiveness, Optimistic Bias, and smoking behavior measures (quit attempts and cessation) were assessed in college-aged Greek student smokers at baseline, end of treatment (3 months), and follow-up (6 months). Using generalized estimating equations, baseline risk perception variables and change in risk perception variables between baseline and end of treatment were examined as predictors of the dichotomous smoking outcome variables. Results revealed that higher baseline PV [OR = 1.42 (1.21, 1.68)] predicted a greater likelihood of a quit attempt (n = 267). An increased likelihood of cessation [OR = 1.41 (1.15, 1.72)] was also predicted by an increase in PV from baseline to end of treatment (n = 243). Overall results suggested that PV was the strongest predictor of smoking behavior change, supporting further examination of health risk perceptions in promoting smoking cessation among Greek college smokers.

There are marked and growing disparities in the health status among different racial/ethnic groups. Most researchers and practitioners agree health interventions that are tailored for specific populations are ethically important and more likely to succeed, yet there are few models for how to tailor interventions. This article outlines three phases and eight activities conducted to increase the cultural sensitivity of a clinical trial assessing the efficacy of bupropion for smoking cessation among African Americans. Early in the project development (Phase I) a strong partnership was built with a community-based clinic, two Advisory Boards were formed (Community and Scientific), and materials were developed. Formative research (Phase II) included a survey to assess smoking cessation needs of clinic patients and exploratory focus groups. Through pilot testing (Phase III), clinic patients tested the intervention components and, in follow-up focus groups, discussed their experiences. Over 13 months the project successfully recruited 523 African Americans into a randomized trial, and preliminary analysis suggest acceptable follow-up rates. Successful recruitment and retention suggests the activities are promising and potentially generalizable. Discussions of these activities illustrate concrete steps researchers and practitioners can take to increase the cultural sensitivity of health promotion and prevention interventions and clinical trials. © 2001 John Wiley & Sons, Inc.

Health education curricula and the delivery of specific health services have been evaluated as to their replicability in other settings. Formal studies to evaluate replication of multicomponent community-based program models are scarce. Moreover the literature does not address the challenges in implementing complex program models and documenting replication. This article describes an initiative to transport and replicate the School/Community Sexual Risk Reduction Model created in South Carolina in three Kansas communities over a 4-year period. Objective and subjective assessments of achieving fidelity to the model core components were determined as was a description of factors that enhance or inhibit replication efforts. Assessing replication will be improved when detailed monitoring and process evaluation is in place in the development of the original program and in the replication effort. (authors)

Children's diet and exercise patterns are affected by numerous environmental factors, including the availability of healthful foods and exercise opportunities in the community, media messages about foods, and family practices regarding physical activity and food choices. Efforts to measure these environmental factors are relatively new. The present paper describes an ecobehavioral perspective on factors influencing health behavior. The authors review the reliability and validity of 16 environmental measures relevant to physical activity and nutrition among youth. To illustrate the use of environmental measures, a case study is provided of how one was used to evaluate two partnerships whose missions were to decrease risk of cardiovascular disease and some cancers among children. The paper closes with recommendations for research and practice.

Background. Many studies on cessation interventions and self-quitting have been conducted, but few have focused on African Americans. The purpose of this review was to critically evaluate the available studies and make recommendations for future research. Methods. Articles published from 1988 to 1998 were collected using Medline and other data bases, as well as personal communication. Studies were divided into two categories: evaluations of specific cessation interventions and examinations of self-quit behaviors and related factors. Studies were tabulated using author/year, study design/sample size, variables/results, and comments. Results. In the intervention studies, church-based programs may provide an effective location for cessation interventions, but the studies to date did not demonstrate unequivocal effectiveness. In clinic programs, there do not appear to be any interventions that are particularly effective. In community-based interventions, there were no differences for African and Caucasian Americans. With regard to self-quitting, sociodemographic variables were similarly related to cessation as in the general population, as were smoking history variables. All other categories did not contain enough information for firm conclusions to be drawn. Conclusions. There are some interventions that appear to be useful, but little information is available on self-quitting. More research is needed on the natural history of quitting, on the social norms for smoking among African American groups, and on the conceptual dimensions of race in the context of this research.

Background. This paper describes a natural, prospective, open-label study designed to evaluate the impact of free nicotine patches with minimal support for smoking cessation. Methods. Surveys were administered to 223 participants who received nicotine patches from the American Lung Association. All participants received a 6-week supply of 15-mg/16-h transdermal nicotine patches, a self-help book Freedom from Smoking , and information about area smoking cessation classes. Follow-up telephone surveys were administered 6 weeks after the patches were distributed. Abstinence was measured through self-report exclusively. Results. The overall quit rate at 6-weeks was 21% (47/223). Among nonquitters, the mean number of cigarettes smoked per day dropped from 25 at baseline to 14 at 6 weeks. There was a significant difference in the average number of patches used by quitters and nonquitters (26 versus 11, P Conclusions. Nicotine patches with minimal support can be effective in smoking cessation and smoking reduction. The availability of patches may have motivated participants to quit. Efforts to increase access to and use of nicotine patches may result in increased attempts to quit and successful quitting.