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Obesity is a well-established risk factor for increased morbidity and mortality. Comprehensive lifestyle interventions, pharmacotherapy, and bariatric surgery are three effective treatment approaches for obesity. The Veterans Health Administration (VHA) offers all three domains but in different configurations across medical facilities. Study aim was to explore the relationship between configurations of three types of obesity treatments, context, and population impact across VHA using coincidence analysis. This was a cross-sectional analysis of survey data describing weight management treatment components linked with administrative data to compute population impact for each facility. Coincidence analysis was used to identify combinations of treatment components that led to higher population impact. Facilities with higher impact were in the top two quintiles for (1) reach to eligible patients and (2) weight outcomes. Sixty-nine facilities were included in the analyses. The final model explained 88% (29/33) of the higher-impact facilities with 91% consistency (29/32) and was comprised of five distinct pathways. Each of the five pathways depended on facility complexity-level plus factors from one or more of the three domains of weight management: comprehensive lifestyle interventions, pharmacotherapy, and/or bariatric surgery. Three pathways include components from multiple treatment domains. Combinations of conditions formed "recipes" that lead to higher population impact. Our coincidence analyses highlighted both the importance of local context and how combinations of specific conditions consistently and uniquely distinguished higher impact facilities from lower impact facilities for weight management.Obesity can contribute to increased rates of ill health and earlier death. Proven treatments for obesity include programs that help people improve lifestyle behaviors (e.g., being physically active), medications, and/or bariatric surgery. In the Veterans Health Administration (VHA), all three types of treatments are offered, but not at every medical center—in practice, individual medical centers offer different combinations of treatment options to their patients. VHA medical centers also have a wide range of population impact. We identified high-impact medical centers (centers with the most patients participating in obesity treatment who would benefit from treatment AND that reported the most weight loss for their patients) and examined which treatment configurations led to better population-level outcomes (i.e., higher population impact). We used a novel analysis approach that allows us to compare combinations of treatment components, instead of analyzing them one-by-one. We found that optimal combinations are context-sensitive and depend on the type of center (e.g., large centers affiliated with a university vs. smaller rural centers). We list five different “recipes” of treatment combinations leading to higher population-level impact. This information can be used by clinical leaders to design treatment programs to maximize benefits for their patients.

Military service presents unique challenges and opportunities for health care and public health. In the USA, there are over 2 million military servicemembers, 20 million veterans, and millions more military and veteran family members. Military servicemembers and eligible family members, many veterans, and retirees receive health care through the two largest learning health care systems in the USA, managed and delivered through the Departments of Defense (DoD), Veterans Affairs (VA), and contracted health care organizations. Through a network of collaborative relationships, DoD, VA, and partnering health care and research organizations (university, corporate, community, and government) accelerate research translation into best practices and policy across the USA and beyond. This article outlines military and veteran health research translation as summarized from a collaborative workshop led by experts across health care research, practice, and administration in DoD, VA, the National Institutes of Health, and affiliated universities. Key themes and recommendations for research translation are outlined in areas of: (a) stakeholder engagement and collaboration; (b) implementation science methods; and (c) funding along the translation continuum. Overall, the ability to rapidly translate research into clinical practice and policy for positive health outcomes requires collaborative relationships among many stakeholders. This includes servicemembers, veterans, and their families along with researchers, health care clinicians, and administrators, as well as policymakers and the broader population.

This article summarizes outcomes of the behavioral interventions work group for the Veterans Health Administration (VHA) State of the Art Conference (SOTA) for Weight Management. Sixteen VHA and non-VHA subject matter experts, representing clinical care delivery, research, and policy arenas, participated. The work group reviewed current evidence of efficacy, effectiveness, and implementation of behavioral interventions for weight management, participated in phone- and online-based consensus processes, generated key questions to address gaps, and attended an in-person conference in March 2016. The work group agreed that there is strong evidence for efficacy and effectiveness of core behavioral intervention components and processes, but insufficient evidence to determine the comparative effectiveness of multiple clinician-delivered weight management modalities, as well as technologies that may or may not supplement clinician-delivered treatments. Effective strategies for implementation of weight management services in VHA were identified. The SOTA work group’s foremost policy recommendations are to establish a system-wide culture for weight management and to identify a population-level health metric to measure the impact of weight management interventions that can be tracked and clearly communicated throughout VHA. The work group’s top research recommendation is to determine how to deploy and scale the most effective behavioral weight management interventions for Veterans.

Healthcare systems are challenged by steady increases in the number of patients who are overweight and obese. Large-scale, evidence-based behavioral approaches for addressing overweight and obesity have been successfully implemented in systems such as the Veterans Health Administration (VHA). These population-based interventions target reduction in risk for obesity-associated conditions through lifestyle change and weight loss, and are associated with modest weight loss. Despite the fact that VHA has increased the overall reach of these behavioral interventions, the number of high-risk overweight and obese patients continues to rise. Recommendations for weight loss medications and bariatric surgery are included in clinical practice guidelines for the management of overweight and obesity, but these interventions are underutilized. During a recent state of the art conference on weight management held by VHA, subject matter experts identified challenges and gaps, as well as potential solutions and overarching policy recommendations, for implementing an integrated system-wide approach for improving population-based weight management.

OBJECTIVE To evaluate the effectiveness of a culturally adapted, primary care–based nurse–community health worker (CHW) team intervention to support diabetes self-management on diabetes control and other biologic measures. RESEARCH DESIGN AND METHODS Two hundred sixty-eight Samoan participants with type 2 diabetes were recruited from a community health center in American Samoa and were randomly assigned by village clusters to the nurse-CHW team intervention or to a wait-list control group that received usual care. RESULTS Participants had a mean age of 55 years, 62% were female, mean years of education were 12.5 years, 41% were employed, and mean HbA1c was 9.8% at baseline. At 12 months, mean HbA1c was significantly lower among CHW participants, compared with usual care, after adjusting for confounders (b = −0.53; SE = 0.21; P = 0.03). The odds of making a clinically significant improvement in HbA1c of at least 0.5% in the CHW group was twice the odds in the usual care group after controlling for confounders (P = 0.05). There were no significant differences in blood pressure, weight, or waist circumference at 12 months between groups. CONCLUSIONS A culturally adapted nurse-CHW team intervention was able to significantly improve diabetes control in the U.S. Territory of American Samoa. This represents an important translation of an evidence-based model to a high-risk population and a resource-poor setting.

There are 2.1 million current military servicemembers and 21 million living veterans in the United States. Although they were healthier upon entering military service compared to the general U.S. population, in the longer term veterans tend to be of equivalent or worse health than civilians. One primary explanation for the veterans' health disparity is poorer health behaviors during or after military service, especially areas of physical activity, nutrition, tobacco, and alcohol. In response, the Department of Defense and Department of Veterans Affairs continue to develop, evaluate, and improve health promotion programs and healthcare services for military and veteran health behavior in an integrated approach. Future research and practice is needed to better understand and promote positive health behavior during key transition periods in the military and veteran life course. Also paramount is implementation and evaluation of existing interventions, programs, and policies across the population using an integrated and person centered approach.

Background The efficacy of a home-based physical activity (PA) intervention for colorectal cancer patients versus contact control was evaluated in a randomized controlled trial. Methods Forty-six patients (mean age = 57.3 years [SD = 9.7], 57% female, mean = 2.99 years post-diagnosis [SD = 1.64]) who had completed treatment for stages 1–3 colorectal cancer were randomized to telephone counseling to support PA (PA group, n = 20) or contact control (control group, n = 26). PA group participants received 3 months of PA counseling (based on the transtheoretical model and the social cognitive theory) delivered via telephone, as well as weekly PA tip sheets. Assessments of PA (Seven-day Physical Activity Recall [7-day PAR] and Community Healthy Activities Model Program for Seniors [CHAMPS]), submaximal aerobic fitness (Treadwalk test), motivational readiness for PA, and psychosocial outcomes were conducted at baseline, 3, 6, and 12 months post-baseline. Objective accelerometer data were collected at the same time points. Results The PA group reported significant increases in minutes of PA at 3 months (7-day PAR) and caloric expenditure (CHAMPS) compared with the control group, but the group differences were attenuated over time. The PA group showed significant improvements in fitness at 3, 6, and 12 months versus the control group. Improvements in motivational readiness for PA were reported in the PA group only at 3 months. No significant group differences were found for fatigue, self-reported physical functioning, and quality of life at 3, 6, and 12 months. Conclusion A home-based intervention improved survivors' PA and motivational readiness at 3 months and increased submaximal aerobic fitness at 3, 6, and 12 months. Copyright © 2011 John Wiley & Sons, Ltd.

Background Patients who have completed Phase II cardiac rehabilitation have low rates of maintenance of exercise after program completion, despite the importance of sustaining regular exercise to prevent future cardiac events. Purpose The efficacy of a home-based intervention to support exercise maintenance among patients who had completed Phase II cardiac rehabilitation versus contact control was evaluated. Design An RCT was used to evaluate the intervention. Data were collected in 2005–2010 and analyzed in 2010. Setting/participants One hundred thirty patients (mean age=63.6 years [SD=9.7], 20.8% female) were randomized to exercise counseling (Maintenance Counseling group, n =64) or contact control (Contact Control group, n =66). Intervention Maintenance Counseling group participants received a 6-month program of exercise counseling (based on the transtheoretical model and social cognitive theory) delivered via telephone, as well as print materials and feedback reports. Main outcome measures Assessments of physical activity (7-Day Physical Activity Recall), motivational readiness for exercise, lipids, and physical functioning were conducted at baseline, 6 months, and 12 months. Objective accelerometer data were collected at the same time points. Fitness was assessed via maximal exercise stress tests at baseline and 6 months. Results The Maintenance Counseling group reported significantly higher exercise participation than the Contact Control group at 12 months (difference of 80 minutes, 95% CI=22, 137). Group differences in exercise at 6 months were nonsignificant. The intervention significantly increased the probability of participants' exercising at or above physical activity guidelines and attenuated regression in motivational readiness versus the Contact Control Group at 6 and 12 months. Self-reported physical functioning was significantly higher in the Maintenance Counseling group at 12 months. No group differences were seen in fitness at 6 months or lipid measures at 6 and 12 months. Conclusions A telephone-based intervention can help maintain exercise, prevent regression in motivational readiness for exercise, and improve physical functioning in this patient population. Trial registration number This study is registered in Clinicaltrials.gov (NCT 00230724).

Translation of research advances into clinical practice for at-risk communities is important to eliminate disease disparities. Adult type 2 diabetes prevalence in the US territory of American Samoa is 21.5%, but little intervention research has been carried out there. We discuss our experience with cultural translation, drawing on an emerging implementation science, which aims to build a knowledge base on adapting interventions to real-world settings. We offer examples from our behavioral intervention study, Diabetes Care in American Samoa, which was adapted from Project Sugar 2, a nurse and community health worker intervention to support diabetes self-management among urban African Americans. The challenges we experienced and solutions we used may inform adaptations of interventions in other settings.

Monthly thorough skin self-examination (TSSE) is an important practice for early melanoma detection that is performed by a small minority of the population.A randomized trial was conducted to determine whether a multicomponent intervention can increase TSSE performance and to describe the effects on performance of skin surgeries compared with a similar control intervention focused on diet.One thousand three hundred fifty-six patients attending a routine primary care visit in southeastern New England participated in this trial.Participants received instructional materials, including cues and aids, a video, and a brief counseling session and (at 3 weeks) a brief follow-up phone call (from a health educator) and tailored feedback letters.Performance of TSSE assessed by telephone interview and having a surgical procedure performed on the skin were confirmed by examining medical records.TSSE was performed by substantially more participants at 2, 6, and 12 months in the intervention group than in the control group (55% vs 35%, p0.0001 at 12 months). We also noted that a substantially higher proportion in the intervention group had skin surgery in the first 6 months (8.0% vs 3.6%, p=0.0005), but there was no difference at 6 to 12 months (3.9% vs 3.3%, p=0.5).The TSSE intervention was effective in increasing performance of TSSE, in that it resulted in increased surgery on the skin, and that increase in skin procedures only persisted for 6 months. Intervention to increase TSSE may result in long-term benefit in early detection of melanoma while causing only a short-term excess of skin surgeries.

Background Regular physical activity reduces the risk for chronic diseases among older adults. Older adults are likely to be seen by primary care clinicians who can play a role in promoting physical activity among their patients. Design In this randomized controlled trial (1998–2003; data analyzed 2004–2005), we compared the effects of brief advice to exercise from a clinician supplemented by telephone-based counseling by health educators (extended advice) to brief advice from a clinician alone (brief advice). Setting/Participants A total of 100 primary care patients (63.2% female, 14.7% minority, mean age=68.5 years) participated in the trial. Interventions The extended-advice intervention consisted of clinician advice plus exercise counseling via telephone provided by research staff, and the brief advice condition consisted of clinician advice alone. Both interventions focused on promoting moderate-intensity physical activity. Main Outcome Measures Self-reported physical activity using the 7-Day Physical Activity Recall instrument and objective activity monitoring using Biotrainers were assessed at baseline, and at 3 and 6 months. Results Participants in the extended-advice arm reported significantly greater participation in moderate-intensity physical activity than the brief-advice group at 3 months (+57.69 minutes vs 12.45 minutes; 3.84 kcal/week vs 0.83 kcal/week) and 6 months (+62.84 minutes vs 16.60 minutes; 4.19 kcal/week vs 1.1 kcal/week). Objective activity monitoring also showed significantly increased physical activity among extended-advice versus brief-advice participants at both time points (+50.79 vs −11.11; +42.39 vs −24.18, respectively). Conclusions These data indicate that clinician advice with follow-up counseling can promote adoption of moderate-intensity physical activity among older, primary care patients.

Background The evidence base regarding what works in practice for helping patients change multiple risk behaviors is less developed than is the more basic literature on behavior change. Still, there is enough consistency of findings to present testable hypotheses for clinicians and administrators to evaluate and guide practice until more definitive evidence is available. Methods The behavior change principles known as the 5A's outline a sequence of support activities (assess, advise, agree, assist, arrange) that are effective for helping patients to change various health behaviors. These same principles also apply at the clinic level for designing activities to support behavior change. Results Successful practices promoting sustainable changes in multiple behaviors are patient centered, tailored, proactive, population based, culturally proficient, multilevel, and ongoing. Often a stepped-care model can be used to provide increasingly intensive (and costly) interventions for patients who are not successful at earlier intervention levels. Conclusions Contextual factors are influential in determining success at both the patient and the office practice level. Therefore, greater attention should be paid to creating supportive family, healthcare system, and community resources and policies. We enumerate 15 hypotheses to be tested for improving patient–clinician interactions and for medical office change.

Background Addressing behavioral risk factors in primary care has become a pressing concern due to the increasing burden of behavioral risk factors on disease, healthcare costs, and public health. Risk factors considered include smoking, risky drinking, sedentary lifestyle, and unhealthy diet—singly or in combination. The already burdened primary care system needs a practical approach to efficiently and effectively address any combination of multiple risk factors. Multiple perspectives and broad insight are urgently needed to gain a deeper understanding of the interacting scientific, systems, and policy issues associated with multiple risk factor interventions (MRFIs). Purpose This paper synthesizes findings from literature reviews, epidemiologic analyses, and structured interactive dialogue sessions, and includes a set of recommendations designed to stimulate further action. Methods Several papers were produced to document current knowledge, research evidence, and salient issues related to multiple risk factor assessment and intervention. Structured interactive dialogue sessions were then conducted with clinician, health system, and health policy leaders regarding what advantage or energy would be liberated by a multiple risk factor approach (rather than separate single risk factor approaches), and how to build a policy framework or constituency for MRFIs. This information is synthesized in this paper. Results There is a clear need to address MRFIs among multiple stakeholders, including patients, purchasers, payers, clinicians, health system leaders, and policy-level stakeholders. MRFIs need to bring with them a compelling value proposition for all stakeholders, and a vision of practical and systematic ways to make it a reality in already-pressed primary care practices. Involving stakeholders in dialogue aimed at helping them see the world through each other's eyes helps overcome discouragement and generates energy for jointly designing new approaches. Recommendations for further action include the creation of multistakeholder dialogue, creation of a policy agenda, development of a translation or integration agenda that connects researchers and practitioners in a two-way exchange, initiation of a series of demonstration projects around MRFIs, and support for research on multiple (rather than only single) risk factor interventions. Conclusions The need to address multiple behavioral risk factors in primary care is increasingly urgent. Whereas stakeholders by themselves may be willing to address multiple risk factors, they agree that it can only be done successfully with a collaborative approach. Findings based on evidence reviews, hypotheses generation, and stakeholder dialogue provide guidance for appropriate further action that, based on what is known already, can be initiated right away.

Background An important barrier to the delivery of health behavior change interventions in primary care settings is the lack of an integrated screening and intervention approach that can cut across multiple risk factors and help clinicians and patients to address these risks in an efficient and productive manner. Methods We review the evidence for interventions that separately address lack of physical activity, an unhealthy diet, obesity, cigarette smoking, and risky/harmful alcohol use, and evidence for interventions that address multiple behavioral risks drawn primarily from the cardiovascular and diabetes literature. Results There is evidence for the efficacy of interventions to reduce smoking and risky/harmful alcohol use in unselected patients, and evidence for the efficacy of medium- to high-intensity dietary counseling by specially trained clinicians in high-risk patients. There is fair to good evidence for moderate, sustained weight loss in obese patients receiving high-intensity counseling, but insufficient evidence regarding weight loss interventions in nonobese adults. Evidence for the efficacy of physical activity interventions is limited. Large gaps remain in our knowledge about the efficacy of interventions to address multiple behavioral risk factors in primary care. Conclusions We derive several principles and strategies for delivering behavioral risk factor interventions in primary care from the research literature. These principles can be linked to the “5A's” construct (assess, advise, agree, assist, and arrange-follow up) to provide a unifying conceptual framework for describing, delivering, and evaluating health behavioral counseling interventions in primary healthcare settings. We also provide recommendations for future research.

Background. Thorough skin self-examination (TSSE) has substantial potential to reduce melanoma mortality by early detection. Methods. We interviewed 2,126 patients before a scheduled routine visit with a primary care physician, at which participation in a randomized trial was offered as part of the Check-It-Out Project. We asked about skin examination behavior and related issues. Results. By our a priori definition of TSSE, 18% of participants performed this activity, but other definitions led to widely varying estimates of 12% to 38%. Using a partner to assist in the examination was strongly associated with TSSE. That partner was generally the spouse, and wives were more likely to assist their husbands in these examinations than the reverse. The availability of a wall mirror was a particularly important predictor of TSSE performance. Visual impairment also affected performance. Conclusions. Estimates of TSSE performance vary substantially with the questions used to elicit this information. Partners, particularly spouses, appear to play a critical role in the conduct of TSSE, and wives appear more often and more effectively engaged in this process. Appropriate circumstances, such as availability of a wall mirror, are also important factors. These findings can be used to design interventions to increase TSSE performance with the ultimate aim of reducing melanoma mortality.

Background We set out to investigate the feasibility of incorporating a computer-tailored health behaviour program into routine care in a group of primary care practices in Rhode Island. Methods Two existing computer programs (physical activity, smoking) that tailored text and graphical feedback to survey responses were combined and adapted for use in primary care directly by patients. Ten primary care practices were recruited and worked closely with project staff to develop a practice-specific plan for incorporating the program into the workflow and office routine. Feasibility was measured by the percentage of patients who used the program during the day of their visit. Results Only one of the ten offices was able to successfully incorporate the program into their office workflow and delivery of routine care. The main categories of barriers to incorporating the computer program into routine care included: • the program was viewed overall as inconsistent with practice workflow • the staff was inexperienced with the program • technical problems with the computer and/or printer • the program placed an additional time burden on staff who already felt overworked. Suggestions for improving the program or the way that it was incorporated into routine care included: • shortening the program • modifying the program’s orientation to a target population (such as patients with hypertension) and incorporating decision-support feedback to help physicians manage the target condition • modifying the program to include other programs pertinent to primary care (for example, depression screening) • selecting patients to use the program, rather than asking all patients to use it. Conclusions After working closely with ten highly motivated primary care offices, we were unable to fully implement a point-of-care health behaviour computer system for patients and providers. Suggestions for disseminating computer-tailored health behaviour communications in primary care settings are discussed.

The goal of evidence-based medicine is ultimately to improve patient outcomes and quality of care. Systematic reviews of the available published evidence are required to identify interventions that lead to improvements in behavior, health, and well-being. Authoritative literature reviews depend on the quality of published research and research reports. The Consolidated Standards for Reporting Trials (CONSORT) Statement (www.consort-statement.org) was developed to improve the design and reporting of interventions involving randomized clinical trials (RCTs) in medical journals. We describe the 22 CONSORT guidelines and explain their application to behavioral medicine research and to evidence-based practice. Additional behavioral medicine-specific guidelines (e.g., treatment adherence) are also presented. Use of these guidelines by clinicians, educators, policymakers, and researchers who design, report, and evaluate or review RCTs will strengthen the research itself and accelerate efforts to apply behavioral medicine research to improve the processes and outcomes of behavioral medicine practice.

Background Little is known about the effectiveness of interventions to disseminate smoking cessation interventions among a population of primary care physicians. This study’s objective was to determine the effect of a community-based academic detailing intervention on the quit rates of a population-based sample of smokers. Methods This community-based, quasi-experimental study involved representative samples of 259 primary care physicians and 4295 adult smokers. An academic detailing intervention was delivered to physicians in intervention areas over a period of 15 months. Analyses were performed on the data from the 2346 subjects who reported at least one physician visit over 24 months. Multivariate regression analyses were conducted to determine the impact of the intervention on self-reported smoking quit rates, reported by adjusted odds ratios. Results Among smokers reporting a physician visit during the study period, there was a borderline significant effect for those residing in intervention areas versus control areas (OR = 1.35; 95% CI .99–1.83; P = 0.057). Among a subgroup of 819 smokers who reported a visit with an enrolled physician, we observed a significant effect for those residing in intervention areas (OR = 1.80; 95% CI 1.16–2.75; P = 0.008). Conclusion An academic detailing intervention to enhance physician delivered smoking cessation counseling is an effective strategy for disseminating smoking cessation interventions among community-based practices.

 Objective: To evaluate dissemination of the Agency for Health Care Policy and Research (AHCPR) Smoking cessation clinical practice guideline in community health centres. Design: Pre- and post-trial. Setting: Fourteen community health centres in Rhode Island. Subjects: Provider performance was assessed with 1798 and 1591 patient contacts, in pre-post cross sectional consecutive samples, respectively, and 891 contacts at one year follow up. Interventions: Three, one hour on-site provider training sessions, on review of effective tobacco interventions, use of office systems, and tobacco counselling skill building. Outcome measures: Chart documentation of four A’s (Ask, Advise, Assist, and Arrange follow up) at most recent primary care visit. Results: While average performance rates increased for Ask and Advise (from 30% to 44%, and 19% to 26%, pre-post, respectively), significant increases were found only for some visit types, with further differences by patient sex. There were significant increases for Ask for all except obstetric/ gynaecological (ob/gyn) visit types. Patients at yearly physicals and first visits were more likely to be asked at all time points, while males were more likely to be asked at acute visits than were females. There were no significant increases for Advise, Assist, and Arrange across time, although female patients showed a differential increase in Advise post-training. Advise was significantly more likely in yearly physicals and first visits, and less likely in ob/gyn visits, at all time points. Conclusions: This guideline dissemination effort resulted in quite different provider counselling rates across patient sexes, and visit types. Guideline implementation may require more sustained efforts, with multiple strategies, which are reinforced at higher policy levels, to more fully integrate tobacco interventions into routine primary care practice with all patients who smoke.

Negative mood, depressive symptoms, and major depressive episodes (MDEs) were examined in 179 smokers with a history of major depression in a trial comparing standard smoking cessation treatment to treatment incorporating cognitive-behavioral therapy for depression (CBT-D). Early lapses were associated with relatively large increases in negative mood on quit date. Mood improved in the 2 weeks after quit date among those returning to regular smoking but not among those smoking moderately. Continuous abstinence was associated with short- and long-term reductions in depressive symptoms. MDE incidence during follow-up was 15.3% and was not associated with abstinence. Unexpected was that CBT-D was associated with greater negative mood and depressive symptoms and increased MDE risk. Results suggest complex bidirectional associations between affect and smoking outcomes.

Background. Little is known about the influence of personal and practice-level factors on physicians' dietary counseling practices. Methods. Primary care physicians ( n = 130) were surveyed regarding the frequency that they “ask” patients about their diet, “assess” patients' reasons for and against dietary changes, “advise” patients to eat less fat and more fiber, “assist” patients in changing their diet, and “arrange” a follow-up contact to discuss their diet. In addition, physicians were asked their personal dietary practices, counseling confidence, practice demographics, and medical specialty. Results. Physicians who (a) reported consistently avoiding dietary fat, (b) were more confident in their diet counseling abilities, and (c) were sole owners of their practice were more likely to counsel than physicians who were employees or part owners of the practice. For example, physicians who reported consistently avoiding dietary fat (50.7% of physicians) were 3.2 (95% CI: 1.3–7.9) times more likely to “ask” their patients about their diet and 3.5 (95% CI: 1.5–8.6) times likely to “advise” their patients to eat less fat and more fiber. Conclusions. Given the strong and consistent effects of a physician's dietary pattern on their counseling practices, future studies should examine the impact of modifying a physician's diet on their patients' dietary behavior.

Academic detailing and data feedback are two methods that have been used to change provider behavior. Academic profiling is proposed as an intervention that combines provider educational outreach and peer-comparison feedback of data generated from chart reviews and health plans. This project assessed the feasibility of academic profiling, using baseline measures to assess provider performance in identifying and treating patients who smoke. The pilot study was undertaken with four primary care practices in Maine. Two health plans shared administrative claims data on adult patients of participating providers. Two educational sessions were conducted: one including feedback of tobacco-related chart documentation and claims for nicotine replacement and bupropion (Zyban®), and the other, coding for tobacco use (ICD-9 305.1) in adults enrolled in two health plans during 1998. A mailed survey assessed provider attitudes following the intervention. Among 24 providers, 80% attended the first session and 70% attended the second session. Provider documentation of tobacco status in the medical records varied from 68% to 100%. The frequency of tobacco pharmacotherapy claims for adult health plan enrollees having a provider visit in 1998 varied from 0% to 4.6% (mean 1.5%) by provider. The frequency of tobacco use diagnosis claims (ICD-9 305.1) varied from 0% to 19.8% by provider. More than 90% of the providers who reviewed the profiling graphs found the data were understandable, and 66% reported that the sessions helped them improve the ways they interact with patients who smoke. Practices vary in tobacco-related documentation, the prescribing of tobacco pharmacotherapy, and the coding for tobacco use. Providers are willing to participate in educational outreach using peer-comparison feedback, presenting opportunities to improve performance in the treatment of tobacco dependence.

The authors examined patterns of change in depressive symptoms during smoking cessation treatment in 163 smokers with past major depressive disorder (MDD). Cluster analysis of Beck Depression Inventory (A. T. Beck, C. H. Ward, M. Mendelson, J. Mock, & J. Erbaugh, 1961) scores identified 5 patterns of change. Although 40% of participants belonged to clusters characterized by increasing depressive symptoms during quitting (rapid increasers, n = 31, and delayed increasers, n = 35), almost 47% were in clusters characterized by decreasing symptoms (delayed decreasers, n = 24, and rapid decreasers, n = 52). Both rapid and delayed increasers had especially poor smoking cessation outcomes. Results suggest that among smokers with an MDD history there is substantial heterogeneity in patterns of depressive symptoms during quitting and that patterns involving increased symptoms are associated with low abstinence rates.

Background: Our objective was to determine whether a tailored, stage-matched educational intervention, guided by the transtheoretical model (TTM), would increase rates of repeat-screening mammography. Design Setting/Participants: A total of 1324 women (N=1026 after attrition) aged 50 to 74 years were recruited from a staff-model health maintenance organization. Some of the women were not due for mammograms at the time of recruitment. Intervention: Women were randomly assigned to one of three intervention conditions: Group 1, no educational materials (usual care); Group 2, standard materials; and Group 3, stage-matched/tailored materials. Women in Groups 2 and 3 received a mailed education packet after both a baseline and a follow-up telephone interview. All women in Group 2 received the same materials regardless of differences in baseline mammography-related attitudes and behaviors. Each woman in Group 3 received materials based on her stage of adoption for mammography and TTM constructs. Main Outcome: Using clinical records, repeat screening was defined as receipt of a second mammogram within 14 months after obtaining an initial postbaseline mammogram. Results: Women in Group 3 were more likely to obtain repeat-screening mammograms than women in Group 1 (44.2% vs 35.8%; adjusted rate ratio = 1.29, 95% confidence interval [CI]=1.11–1.46; adjusted rate difference = 0.06, 95% CI=−0.01–0.13). The screening percentage in Group 2 was intermediate (39.3%), and did not differ from either Group 3 or Group 1. Conclusions: The effect of the stage-matched/tailored intervention was sustained for repeat screening, although no educational materials were delivered to coincide with the timing for a second mammogram. However, the stage-matched/tailored intervention was not sufficient to have a substantial impact on screening beyond the effect of standard educational materials. Future interventions may need to administer “booster” sessions to increase repeat screenings.

The authors evaluated the efficacy of fluoxetine hydrochloride (Prozac; Eli Lilly and Company, Indianapolis, IN) as an adjunct to behavioral treatment for smoking cessation. Sixteen sites randomized 989 smokers to 3 dose conditions: 10 weeks of placebo, 30 mg, or 60 mg fluoxetine per day. Smokers received 9 sessions of individualized cognitive-behavioral therapy, and biologically verified 7-day self-reported abstinence follow-ups were conducted at 1, 3, and 6 months posttreatment. Analyses assuming missing data counted as smoking observed no treatment difference in outcomes. Pattern-mixture analysis that estimates treatment effects in the presence of missing data observed enhanced quit rates associated with both the 60-mg and 30-mg doses. Results support a modest, short-term effect of fluoxetine on smoking cessation and consideration of alternative models for handling missing data.

Objectives To evaluate implementing two training models for motivational interviewing (MI) to address tobacco use with primary care clinicians. Methods Clinicians were randomized to moderate or high intensity. Both training modalities included a single ½ day workshop facilitated by MI expert trainers. The high intensity (HI) training provided six booster sessions including telephone interactions with simulated patients and peer coaching by MI champions over 3 months. To assess performance of clinicians to deliver MI, an objective structured clinical evaluation (OSCE) was conducted before and 12 weeks after the workshop training. Results Thirty-four clinicians were enrolled; 18 were randomly assigned to HI. Compared to the moderate intensity group, the HI group scored significantly higher during the OSCE for three of six global Motivational Interviewing Treatment Integrity scale scores. There was also significant improvement for three of the four measures of MI counseling knowledge, skills and confidence. Conclusions Using champions and telephone interactions with simulated patients as enhancement strategies for MI training programs is feasible in the primary care setting and results in greater gains in MI proficiency. Practice implications Results confirm and expand evidence for use of booster sessions to improve the proficiency of MI training programs for primary care clinicians.

We utilized cluster analysis to identify individual differences in response to the initial effects of smoking following overnight abstinence among 183 regular smokers. Participants smoked three cigarettes (1 mg nicotine, spaced 30 min apart) in standardized fashion and completed questionnaires about their subjective responses to each cigarette. Heart rate was monitored throughout the procedure. Participants were grouped into two clusters based on their reported subjective effects and heart rate changes to the first cigarette. Clusters differed in terms of greater increases in heart rate, reports of dizziness, sweating, unpleasantness, nausea, and buzzing sensations in one group compared to the other group. The smokers showing increased responses developed greater acute tolerance to the effects of smoking subsequent cigarettes on subjective negative effects and heart rate, and experienced greater negative affect after quitting. These results are partially consistent with a nicotine sensitivity interpretation or a tolerance model of the effects of initial smoking.

Both nicotine dependence and coping are important determinants of smoking cessation, yet little is understood about mechanisms that link the two. This laboratory study investigated how nicotine dependence moderates execution of an avoidance coping strategy. High and low dependent smokers were exposed to a provocative smoking cue (in vivo) under two instructional sets: cognitive avoidance coping and no coping. Contrary to hypotheses, high dependent smokers reported greater increases in perceived self-efficacy to not smoke and also demonstrated greater facility in processing coping/nonsmoking-related information on a reaction time task, compared with low dependent smokers. These counterintuitive findings are discussed in terms of how nicotine dependence may affect the cognitive process of coping.

Lifestyle factors related to obesity, eating behavior, and physical activity play a major role in the prevention and treatment of type 2 diabetes. In recent years, there has been progress in the development of behavioral strategies to modify these lifestyle behaviors. Further research, however, is clearly needed, because the rates of obesity in our country are escalating, and changing behavior for the long term has proven to be very difficult. This review article, which grew out of a National Institute of Diabetes and Digestive and Kidney Diseases conference on behavioral science research in diabetes, identifies four key topics related to obesity and physical activity that should be given high priority in future research efforts: 1) environmental factors related to obesity, eating, and physical activity; 2) adoption and maintenance of healthful eating, physical activity, and weight; 3) etiology of eating and physical activity; and 4) multiple behavior changes. This review article discusses the significance of each of these four topics, briefly reviews prior research in each area, identifies barriers to progress, and makes specific research recommendations.

Symptoms of depression have been associated with increased smoking prevalence and failure to quit smoking in several cross-sectional and population-based studies. Few studies, however, have prospectively examined the ability of current symptoms of depression to predict failure to quit smoking in treatment-motivated smokers. Pretreatment depressed mood was assessed by 3 different methods in 3 separate samples, 2 of which comprised smokers receiving combined pharmacological and behavioral treatments and a 3rd in which smokers received self-help materials only. In all studies, time in days from quit day until the 1st cigarette was ascertained to document survival. Survival analyses showed that in all 3 studies survival time was significantly and negatively related to measures of even very low levels of pretreatment depressed mood. Results were replicated across 3 independent samples and were robust and uniformly clear, indicating that low levels of depressive symptoms assessed at baseline predict time to 1st cigarette smoked after attempted quitting.

Cigarette smokers with past major depressive disorder (MDD) received 8 group sessions of standard, cognitive-behavioral smoking cessation treatment (ST; n = 93) or standard, cognitive-behavioral smokiig cessation treatment plus cognitive-behavioral treatment for depression (CBT-D; n = 86). Although abstinence rates were high in both conditions (ST, 24.7%; CBT-D, 32.5%, at 1 year) for these nonpharmacological treatments, no main effect of treatment was found. However, secondary analyses revealed significant interactions between treatment condition and both recurrent depression history and heavy smoking ( > or =25 cigarettes a day) at baseline. Smokers with recurrent MDD and heavy smokers who received CBT-D were significantly more likely to be abstinent than those receiving ST (odds ratios = 2.3 and 2.6, respectively). Results suggest that CBT-D provides specific benefits for some, but not all, smokers with a history of MDD.

The two purposes of this investigation were: (a) to examine whether an association existed between stages of adopting regular mammography and decision-making constructs from the Transtheoretical Model (TTM) of behavior change, and (b) to determine whether any such associations would be found for each of the two ways of defining the stages-of-adoption. One method integrated past screening history with a report of future intention for screening; the other method used a single item with predetermined response categories. Data were from the baseline survey of 1,323 women aged 50–74 who were recruited as part of an intervention study through a local Health Maintenance Organization. Results showed that both ways of defining stages of adopting regular mammography were associated with decisional balance and processes-of-change. The method that integrated past history plus intention provided somewhat better discrimination among stages. Women who were labeled as being at “Risk of Relapse,” and those who said they waited for a “Provider’s Recommendation,” may be useful groups to add to the set of stages that have been employed so far by the TTM. In addition, a tendency to avoid the health care system in general was used as a process-of-change to complement the mammography-specific processes.

The purpose of this study was to explore the relationship between the Big Five personality dimensions and smoking variables. Thirty-seven smokers completed a standard, reliable 80-item bipolar measure of the Big Five trait dimensions, as well as measures of nicotine dependence, smoking exposure, and quitting history. Despite finding some significant zero-order relationships between a few of the dimensions and the smoking variables, only one of the partial correlational analyses that controlled for relationships among the personality dimensions in their associations with the nicotine dependence and smoking history variables was significant. These results indicate the need for further research on personality traits and smoking.

Considerable research shows that withdrawal severity is inconsistently related to smoking cessation outcomes. This may result from measurement problems or failure to scrutinize important dimensions of the withdrawal experience. Two recent studies demonstrated that withdrawal elevation and variations in the time course of withdrawal were related to relapse in smokers treated with the nicotine patch (T. M. Piasecki, M. C. Fiore, & T. B. Baker, 1998). This article reports a conceptual replication and extension of those findings in unaided quitters. Evidence for temporal heterogeneity was found across different types of withdrawal symptoms. Patterns or slopes of affect and urge reports over time predicted smoking status at follow-up, as did mean elevation in withdrawal symptoms. These results suggest that affect and urge withdrawal symptoms make independent contributions to relapse and that relapse is related to both symptom severity and trajectory.

The evidence linking smoking and coronary artery disease is quite strong, and there is also a positive relationship between smoking cessation and reduction in cardiovascular disease risk. Nicotine replacement therapy and bupropion are effective treatments for smoking cessation and are most effective when combined with behavioral counseling. Intensive multicomponent interventions that include a case-management component have produced the highest smoking cessation rates for patients who suffer a myocardial infarction.

Background: Melanoma is a major public health problem for which early detection may reduce mortality. Since melanoma is generally asymptomatic, this requires skin examination. We sought to evaluate the extent to which the general public has their skin examined by themselves, their partners, or health care providers and the frequency of these examinations. Methods: Random-digit-dial survey of adult Rhode Islanders. Results: Only 9% performed a thorough skin examination (TSE) at least once every few months, although over half of the sample reported conducting skin self-examination “deliberately and systematically.” Participants were more likely to perform TSE if they were women and if their health care provider had asked them to examine their skin. Most participants reported that their health care provider never or rarely looked at the areas of their skin in which melanoma is most likely to arise. Conclusions: The reported frequency of skin self-examination depends critically on the manner of inquiry. TSE by self or a partner is uncommon, and health care providers do not routinely examine the areas of the skin on which melanomas commonly arise.

BACKGROUND Cancer clinicians do not receive routine training in the psychosocial aspects of patient care such as how to communicate bad news or respond to patients who have unrealistic expectations of cure. Postgraduate workshops may be an effective way to increase interpersonal skills in managing these stressful patient encounters. METHODS The authors conducted 2 half-day workshops for oncology faculty, one on breaking bad news and one on dealing with “problem situations.” Participants met in a large group for didactic presentations and then small groups in which they used role-play and discussion to problem-solve difficult cases from their practices. The small groups were assisted in their work by trained physician facilitators. The workshops were evaluated by means of a follow-up satisfaction questionnaire as well as a self-efficacy measure, which was administered before and after the workshops. RESULTS Twenty-seven faculty and 2 oncology fellows participated in the training programs. Satisfaction questionnaires showed that the programs met the educational objectives and were considered to be useful and relevant by the participants. Self-efficacy questionnaires revealed an increase in confidence in communicating bad news and managing problem situation cases from before to after the workshop. The majority of attendees welcomed the opportunity to discuss their difficult cases with colleagues. A number resolved to implement newly learned approaches to common patient problems they encountered frequently. CONCLUSIONS Communication skills workshops may be a useful modality to provide training to oncologists in stressful aspects of the physician-patient relationship. Further research is needed to assess whether long term benefits accrue to the participants. [See editorial on pages 738-40, this issue.] Cancer 1999;86:887–97. © 1999 American Cancer Society.

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

Background.Tailoring is a promising technique for encouraging greater performance of health-related behaviors. Tailored interventions are designed to be more individualized to personal characteristics, in contrast to “standard” interventions where all participants receive the same materials. Methods.A total ofN= 1864 women aged 40–74 were recruited from a staff model HMO and randomly assigned to one of three intervention groups: (a) No Educational Materials, (b) Standard Materials, and (c) Stage-Matched Materials. A provider-directed component was common across all three conditions. The Standard and Stage-Matched groups each received two mailed educational packets after baseline and follow-up telephone interviews. The Stage-Matched intervention was based on the Transtheoretical Model of behavior change. Results.Analyses ofn= 1397 women (after all attrition) showed that receipt of mammography after the baseline interview was higher for the Stage-Matched group (63.6%) than for the No Materials group (54.9%; OR = 1.43, 95% CI = 1.10, 1.86). The Standard intervention group was intermediate (58.5%). The Standard group did not differ from the No Materials group, but did differ from the Stage-Matched group in multivariate analysis. Conclusions.Stage-matched, tailored materials may be a means to encourage screening mammography. Such interventions can be implemented by telephone and mail.

Background: The continued prevalence of sedentary behavior in older adults underscores the need for physical activity promotion. Physician-delivered activity counseling may be an important avenue of promoting physical activity for these individuals. The Physically Active for Life (PAL) project was a randomized study of the effects of brief physician counseling plus follow-up on physical activity behaviors in older adults. Method: Twelve practices were randomized to the intervention group and 12 to standard care. Physicians in the intervention group participated in a 1-hour training session and received support materials for exercise counseling. Pre-assessment and post-assessment of self-reported exercise counseling behaviors and confidence in providing exercise counseling were obtained from physicians in the study. Patient evaluations of the exercise counseling and support materials were also obtained. Results: Results showed that physicians favorably endorsed the training and the support materials, and reported adherence to delivery of the intervention protocol. Comparisons between the two groups showed significant improvements in confidence for intervention-group physicians, but no significant changes in physician reports of exercise counseling provided to all patients. Patients reported satisfaction with the exercise counseling and support materials. Conclusions: Physicians and patients indicated the PAL project offered an acceptable and feasible approach to promote physical activity in older adults.

Modifying patients' sedentary lifestyle, a risk factor for many chronic diseases, is a challenge to health professionals. Although physicians can play a vital role in promoting physical activity among sedentary patients, the prevalence of physician-based exercise counseling is low. This paper presents a review of studies that have targeted physicians as agents of behavior change. Changing sedentary behavior is more likely to be effective when the intervention is grounded in theory. This paper outlines an integration of two theoretical models that have potential for enhancing behavior change, and it describes specific techniques for physicians interested in promoting a more active lifestyle among their patients.

The affectively valenced scripts used by S. Tiffany (1990) suggest that different scripts produce relatively equivalent levels of cue reactivity, although it is unclear if these laboratory findings generalize to clinical samples. In this study, cessation-motivated smokers were tested 7 days before they tried to quit smoking and were exposed to 3 audiotaped scripts that depicted different affectively valenced situations (neutral, positive, or negative). The latter 2 scripts also contained smoking cues. The findings using a clinical sample differed considerably from those using analogue laboratory samples across affective, cognitive, and physiological response measures. Reactivity to these standardized scripts failed to predict treatment outcome through a 30-day follow-up. The use of affectively valenced scripts beyond a laboratory sample is questioned.

Background. The ability to study health-related behaviors in combination rather than singly will lead to a more comprehensive approach to health promotion. This investigation focused on mammography and Pap testing. One index was created to reflect the recency of receiving both examinations. A second index integrated opinions about the two procedures into a single measure, guided by the pros, cons, and decisional balance constructs of the Transtheoretical Model of behavior change. Method. Data were drawn from the baseline and 1-year follow-up surveys of an HMO sample of women ages 40–74 ( N = 1,605). Data collection occurred by telephone. A series of analyses examined whether recency of screening was associated with opinions about screening. Results. The first analysis showed that recency of Pap testing and whether or not a Pap test was obtained between the two surveys were associated with opinions about Pap testing. The next analysis examined the association between the indicator for regularity of both Pap testing and mammography, with the measure of opinions toward the two procedures. The variable measuring receipt of Pap test and mammography was associated with the combined measure of opinions. Conclusions. The ability to employ combined indicators for recency of testing and test-related opinions is promising for being able to take a more comprehensive approach to women's health. The paper discusses methodological considerations that arise when attempting to integrate two or more behaviors.

A consensus conference on the reasons for the undertreatment of depression was organized by the National Depressive and Manic Depressive Association (NDMDA) on January 17–18,1996. The target audience included health policymakers, clinicians, patients and their families, and the public at large. Six key questions were addressed: (1) Is depression undertreated in the community and in the clinic? (2) What is the economic cost to society of depression? (3) What have been the efforts in the past to redress undertreatment and how successful have they been? (4) What are the reasons for the gap between our knowledge of the diagnosis and treatment of depression and actual treatment received in this country? (5) What can we do to narrow this gap? (6) What can we do immediately to narrow this gap?

Objective. —A consensus conference on the reasons for the undertreatment of depression was organized by the National Depressive and Manic Depressive Association (NDMDA) on January 17-18, 1996. The target audience included health policymakers, clinicians, patients and their families, and the public at large. Six key questions were addressed: (1) Is depression undertreated in the community and in the clinic? (2) What is the economic cost to society of depression? (3) What have been the efforts in the past to redress undertreatment and how successful have they been? (4) What are the reasons for the gap between our knowledge of the diagnosis and treatment of depression and actual treatment received in this country? (5) What can we do to narrow this gap? (6) What can we do immediately to narrow this gap? Participants. —Consensus panel members were drawn from psychiatry, psychology, family practice, internal medicine, managed care and public health, consumers, and the general public. The panelists listened to a set of presentations with background papers from experts on diagnosis, epidemiology, treatment, and cost of treatment. Evidence. —Experts summarized relevant data from the world scientific literature on the 6 questions posed for the conference. Consensus Process. —Panel members discussed openly all material presented to them in executive session. Selected panelists prepared first drafts of the consensus statements for each question. All of these drafts were read by all panelists and were edited and reedited until consensus was achieved. Conclusions. —There is overwhelming evidence that individuals with depression are being seriously undertreated. Safe, effective, and economical treatments are available. The cost to individuals and society of this undertreatment is substantial. Long suffering, suicide, occupational impairment, and impairment in interpersonal and family relationships exist. Efforts to redress this gap have included provider educational programs and public educational programs. Reasons for the continuing gap include patient, provider, and health care system factors. Patient-based reasons include failure to recognize the symptoms, underestimating the severity, limited access, reluctance to see a mental health care specialist due to stigma, noncompliance with treatment, and lack of health insurance. Provider factors include poor professional school education about depression, limited training in interpersonal skills, stigma, inadequate time to evaluate and treat depression, failure to consider psychotherapeutic approaches, and prescription of inadequate doses of antidepressant medication for inadequate durations. Mental health care systems create barriers to receiving optimal treatment. Strategies to narrow the gap include enhancing the role of patients and families as participants in care and advocates; developing performance standards for behavioral health care systems, including incentives for positive identification, assessment, and treatment of depression; enhancing educational programs for providers and the public; enhancing collaboration among provider subtypes (eg, primary care providers and mental health professionals); and conducting research on development and testing of new treatments for depression.