An empirical typology of subjects within stage of change

Comparing Telephone Counseling With Reminding to Promote On-Time Repeated Mammography: A Randomized Trial in a Cohort With 4 Years Follow-Up

Background. Long-term continuous adherence to biennial screening mammograms as guidelines recommend remains low. Limited evidence suggests that reminder calls may increase short-term adherence as much as telephone counseling, but research is needed comparing the long-term effects of these two approaches. Purpose. To compare the impacts of two telephone outreach interventions and mailed reminders on 4-year continuous mammography adherence. Method. A cohort of 3,215 women, age 50 to 81 years, was selected from 30,160 women from a 4-year randomized trial of three interventions to promote biennial mammography: reminder letter only (LO), letter plus reminder call (RC), and two letters plus educational material and a counseling call (CC). Women selected remained eligible for the trial all 4 years and received annual interventions as needed. The proportion with a mammogram in the last 24 months was determined at baseline and four annual time points. Results. Continuous adherence at all four time points was higher in the RC (78.8%) and CC arms (78.8%) than in the LO arm (75.1%; p < .001). Multivariable analysis confirmed this finding: CC (odds ratio = 1.27; 95% confidence interval = [1.01, 1.61]) and RC (odds ratio = 1.23; 95% confidence interval = [0.98, 1.56]). Only 27.8% of women eligible for an initial counseling call actually received counseling. Conclusions. Compared with letters alone, outreach calls can modestly increase continuous mammography adherence among insured women with consistent primary care. Telephone counseling was no more effective than a reminder call, possibly due to limited acceptance of counseling calls by women who may find them unwelcome or unnecessary.

Smokers who do not quit: Can the precaution adoption process model help identify hard-core smokers?

Introduction

Hard-core smokers have been identified as a potential public health challenge. The trans-theoretical model lacks the specificity to identify hard-core smokers. The precaution adoption process model (PAPM) is a stage-based behaviour change model which includes ‘no intent to quit’ as a distinct stage and so may be useful in identifying hard-core smokers.

Aims

The aim of this study was to apply the PAPM to a community based sample of smokers to determine whether it provides a useful approach to identifying hard-core smokers.

Methods

We surveyed smokers in Australia who were recruited through social media and an online data collection agency.

Results

The sample included 336 current smokers, 11.9% were in Stage 4 of the PAPM – i.e. had decided not to quit. Stage 4 smokers are more resistant to quitting and marked by their similarities to hard-core smokers. This is further amplified when addressing Stage 4 smokers with no previous quit attempt.

Conclusions

Stage 4 smokers with no previous quit attempts are aligned with a hard-core smoker profile with higher levels of nicotine dependence, greater cigarette consumption and low socio-economic status. Further research is required to determine if PAPM is a valid predictive model for identifying hard-core smokers in clinical practice.

Recruitment and effectiveness by cohort in a case management intervention among American Indians and Alaska Natives with diabetes

In real-world settings, eligible populations and intervention effectiveness for a translational intervention likely vary across time. To determine the optimal strategies for effective large-scale implementation of evidence-based interventions, it is critical to investigate these potential variabilities. The purpose of this study is to evaluate whether patient characteristics and intervention effectiveness differed by year of enrollment in a multiyear evidence-based translational intervention. The Special Diabetes Program for Indians Healthy Heart (SDPI-HH) Demonstration Project is an intensive case management intervention designed to reduce cardiovascular disease risk among American Indians and Alaska Natives with diabetes. SDPI-HH participants recruited from 2006 through 2008 were included. Baseline characteristics were compared by year of enrollment. We also evaluated the differences in improvements in clinical and behavioral risk factors for cardiovascular disease among participants recruited in different years. The baseline characteristics of the three cohorts significantly differed in demographics, diabetes duration, health behaviors, level of motivation, and clinical measures. Improvements in 13 clinical and behavioral outcomes also differed by enrollment year with the 2006 cohort having the greatest number of significant improvements and the highest rates of participation and retention. Further investigation into the ways to modify the intensive case management model to address differences in levels of motivation and participation is warranted to improve the management of chronic disease in Indian health. Given the evolving nature of translational initiatives of this kind, our analysis results highlight the need to understand and adapt during the natural progression of health behavioral interventions.

Subgroups Among Smokers in Preparation: A Cluster Analysis Using the I-Change Model

BACKGROUND

Investigating potential sub-stages of change could provide important information that could be used to improve the tailoring of smoking cessation interventions to individual smokers' profiles. Smokers in the preparation stage may be most interesting, as they are most likely to participate in smoking cessation interventions.

OBJECTIVE

To examine whether Dutch adult smokers in the preparation stage of change, i.e. motivated to quit smoking within one month, can be organized into subgroups.

METHODS

Data from 753 smokers who participated in an effectiveness trial of a web-based, computer-tailored smoking cessation programme were subjected to secondary analysis. Cluster analyses were based on respondents' baseline responses to items on pros and cons of quitting and quitting self-efficacy. Chi-squared tests and ANOVA were used to compare the baseline characteristics of the resulting clusters. Logistic and multinomial regression were used for longitudinal comparisons of clusters with respect to smoking abstinence and stage transition at six-week and six-month follow-ups.

RESULTS

Four clusters were identified; Classic, Unprepared, Progressing and Disengaged Preparers. Cross-sectional and longitudinal analyses validated these clusters: they differed with respect to the clustering variables, gender, cigarette dependence and educational level. Disengaged Preparers were less likely than Progressing Preparers to report smoking abstinence at six months (OR = 0.28; p < .05).

CONCLUSIONS

These results suggest that smoking cessation interventions tailored to the preparation stage of change, i.e. the set of cognitions usually present in preparers, are only appropriate for the subgroup we defined as Classic Preparers. The other clusters might need different interventions as they display different cognition sets.

Types of Smokers Who Seek Smoking Cessation Treatment According to Psychopathology

Psychopathology and psychological distress have been shown to be related to poor smoking cessation outcomes and abstinence maintenance. Thus, it is important to identify individuals with high levels of psychopathology before undergoing smoking cessation treatment in order to increase their likelihood of success.

OBJECTIVE

The primary aim of the present study was to analyze whether we could classify smokers by using self-reported measures of psychopathology. In addition, a secondary aim was to examine if there were significant differences among the groups of smokers regarding sociodemographic information, nicotine dependence, and cessation rates at the end of treatment and at 6- and 12-month follow-ups.

METHODS

Participants were 281 smokers seeking smoking cessation treatment. Participants were classified into different smoking groups by using a 2-step cluster analysis based on baseline scores on the Restructured Clinical (RC) scales of the Minnesota Multiphasic Personality Inventory-2 Restructured Form (MMPI-2-RF), Beck Depression Inventory-II (BDI-II), and State-Trait Anxiety Inventory (STAI).

RESULTS

Smokers were classified into 3 groups according to levels of psychopathology: Low (n = 158), Intermediate (n = 78), and High (n = 45). Smokers in the High Group were more likely to present higher levels of psychopathology and to continue smoking at the end of treatment when compared with the two other clusters. In addition, smokers classified in this group were more likely to be nicotine dependent and from a low social class.

CONCLUSIONS

A subgroup of smokers can be easily identified through self-report measures of psychopathology. Furthermore, these individuals were more likely to continue smoking at the end of treatment. This suggests that this group with high levels of psychopathology might benefit from future interventions that are more intensive or cessation treatments targeted to their specific characteristics.

A Stage Model of Blood Donor Behaviour: Assessing Volunteer Behaviour

Are there valid stages to explain blood donor behaviour? Three studies (event contingent diary, interview and psychometric) are reported that address this question. Stage and process constructs from the transtheoretical model (TTM), past behaviour and intentions are measured. The qualitative studies demonstrated that blood donors describe their behaviour using TTM constructs. The psychometric study identified: (1) groupings of blood donors consistent with Ferguson’s (1996) stage predictions; (2) TTM constructs varied meaningfully as a function of these groupings; (3) associations within clusters indicated qualitatively distinct stages; and (4) TTM constructs showed incremental validity over intentions with respect to past behaviour.

Stages of Adopting Regular Screening Mammography

This study examined whether distinct subgroups of women could be identified within stages of adoption for screening mammography. These subgroups may represent differential readiness to move to the next stage of the adoption continuum. Data were from a baseline survey of 1323 women between the ages of 50 and 74 years who were recruited through a staff- model HMO for an intervention study to increase rates of mammography. Multiple regression models were used to identify correlates of positive decisional balance within each of four stages of adoption, and an index of positive indicators was developed from the significant correlates for each stage. Analysis of variance showed that the number of positive indicators discriminated women within each stage. This information can be used to develop more effective tailored interventions to increase the percentage of women receiving mammograms on a regular schedule.

[To take into account addicted patients' motivation to seek treatment. About a case report of a disordered gambler]

Only few subjects with addictive disorders seek treatment. Early identification and intervention are capital. Compliance for addictions' treatment remains low. Motivation enhancement promotes alliance and therapeutic compliance. Therapeutic goals should be discussed with the patient. It is important to diagnose the psychiatric and addictive comorbid disorders, which are frequent.

Identifying Subgroups among Hardcore Smokers: a Latent Profile Approach

INTRODUCTION

Hardcore smokers are smokers who have little to no intention to quit. Previous research suggests that there are distinct subgroups among hardcore smokers and that these subgroups vary in the perceived pros and cons of smoking and quitting. Identifying these subgroups could help to develop individualized messages for the group of hardcore smokers. In this study we therefore used the perceived pros and cons of smoking and quitting to identify profiles among hardcore smokers.

METHODS

A sample of 510 hardcore smokers completed an online survey on the perceived pros and cons of smoking and quitting. We used these perceived pros and cons in a latent profile analysis to identify possible subgroups among hardcore smokers. To validate the profiles identified among hardcore smokers, we analysed data from a sample of 338 non-hardcore smokers in a similar way.

RESULTS

We found three profiles among hardcore smokers. 'Receptive' hardcore smokers (36%) perceived many cons of smoking and many pros of quitting. 'Ambivalent' hardcore smokers (59%) were rather undecided towards quitting. 'Resistant' hardcore smokers (5%) saw few cons of smoking and few pros of quitting. Among non-hardcore smokers, we found similar groups of 'receptive' smokers (30%) and 'ambivalent' smokers (54%). However, a third group consisted of 'disengaged' smokers (16%), who saw few pros and cons of both smoking and quitting.

DISCUSSION

Among hardcore smokers, we found three distinct profiles based on perceived pros and cons of smoking. This indicates that hardcore smokers are not a homogenous group. Each profile might require a different tobacco control approach. Our findings may help to develop individualized tobacco control messages for the particularly hard-to-reach group of hardcore smokers.

Assessing motivation and readiness to change for weight management and control: an in-depth evaluation of three sets of instruments

It is highly recommended to promptly assess motivation and readiness to change (RTC) in individuals who wish to achieve significant lifestyle behavior changes in order to improve their health, overall quality of life, and well-being. In particular, motivation should be assessed for those who face the difficult task to maintain weight, which implies a double challenge: weight loss initially and its management subsequently. In fact, weight-control may be as problematic as smoking or drugs-taking cessation, since they all share the commonality of being highly refractory to change. This paper will examine three well-established tools following the Transtheoretical Model, specifically assessing RTC in weight management: the University of Rhode Island Change Assessment Scale, the S-Weight and the P-Weight and the Decisional Balance Inventory. Though their strengths and weaknesses may appear to be rather homogeneous and similar, the S-Weight and P-Weight are more efficient in assessing RTC in weight management and control. Assessing motivation and RTC may be a crucial step in promptly identifying psychological obstacles or resistance toward weight-management in overweight or obese hospitalized individuals, and it may contribute to provide a more effective weight-control treatment intervention.

[Psychoeducational Smoking Cessation Groups in an Acute Psychiatry Ward]

BACKGROUND

In view of the high prevalence of dependent smokers in psychiatric inpatient facilities advice for smoking cessation seems crucial. Due to the relatively short duration of stay in acute psychiatric wards (in our facility < 2 weeks) there is a need for therapeutic concepts that link to outpatient settings. The transtheoretical model by "Prochaska and DiClemente" (TTM) seems suitable to create an appropriate therapeutic concept.

METHODS

At the department of adult psychiatry located at Tulln university hospital, Austria, psychoeducational groups for smoking cessation were conducted. Apart from the degree of dependence using Fagerström test for nicotine-dependence (FTND), 100 mm visual analogue scales (VAS) were utilized to evaluate the patients' motivation for quitting smoking (100 VAS: maximimum motivation), the presenting physician (100 VAS: best performance), the content (100 VAS: best content) and the comprehensibility (100 VAS: optimum understanding).

RESULTS

Out of 37 participants, the majority (89.2 %), showed a moderate to very strong nicotine dependence. The median motivation for smoking cessation was 56 VAS, the median change in motivation 67 VAS, the content 96 VAS, comprehensibility 94 VAS and presenter was rated with 95 VAS.

CONCLUSIONS

In general, patients showed high levels of nicotine dependence. The psychoeducational group was predominantly evaluated in a positive way. Individual change in motivation to quit smoking might correspond to a stage in the TTM making a collaboration with outpatient facilities inevitable.

Replicating cluster subtypes for the prevention of adolescent smoking and alcohol use

INTRODUCTION

Substance abuse interventions tailored to the individual level have produced effective outcomes for a wide variety of behaviors. One approach to enhancing tailoring involves using cluster analysis to identify prevention subtypes that represent different attitudes about substance use. This study applied this approach to better understand tailored interventions for smoking and alcohol prevention.

METHODS

Analyses were performed on a sample of sixth graders from 20 New England middle schools involved in a 36-month tailored intervention study. Most adolescents reported being in the Acquisition Precontemplation (aPC) stage at baseline: not smoking or not drinking and not planning to start in the next six months. For smoking (N=4059) and alcohol (N=3973), each sample was randomly split into five subsamples. Cluster analysis was performed within each subsample based on three variables: Pros and Cons (from Decisional Balance Scales), and Situational Temptations.

RESULTS

Across all subsamples for both smoking and alcohol, the following four clusters were identified: (1) Most Protected (MP; low Pros, high Cons, low Temptations); (2) Ambivalent (AM; high Pros, average Cons and Temptations); (3) Risk Denial (RD; average Pros, low Cons, average Temptations); and (4) High Risk (HR; high Pros, low Cons, and very high Temptations).

CONCLUSIONS

Finding the same four clusters within aPC for both smoking and alcohol, replicating the results across the five subsamples, and demonstrating hypothesized relations among the clusters with additional external validity analyses provide strong evidence of the robustness of these results. These clusters demonstrate evidence of validity and can provide a basis for tailoring interventions.

Typology of alcohol users based on longitudinal patterns of drinking

OBJECTIVE

Worldwide, alcohol is the most commonly used psychoactive substance. However, heterogeneity among alcohol users has been widely recognized. This paper presents a typology of alcohol users based on an implementation of idiographic methodology to examine longitudinal daily and cyclic (weekly) patterns of alcohol use at the individual level.

METHOD

A secondary data analysis was performed on the pre-intervention data from a large randomized control trial. A time series analysis was performed at the individual level, and a dynamic cluster analysis was employed to identify homogenous longitudinal patterns of drinking behavior at the group level. The analysis employed 180 daily observations of alcohol use in a sample of 177 alcohol users.

RESULTS

The first order autocorrelations ranged from -.76 to .72, and seventh order autocorrelations ranged from -.27 to .79. Eight distinct profiles of alcohol users were identified, each characterized by a unique configuration of first and seventh autoregressive terms and longitudinal trajectories of alcohol use. External validity of the profiles confirmed the theoretical relevance of different patterns of alcohol use. Significant differences among the eight subtypes were found on gender, marital status, frequency of drug use, lifetime alcohol dependence, family history of alcohol use and the Short Index of Problems.

CONCLUSIONS

Our findings demonstrate that individuals can have very different temporal patterns of drinking behavior. The daily and cyclic patterns of alcohol use may be important for designing tailored interventions for problem drinkers.

Control Systems Engineering for Understanding and Optimizing Smoking Cessation Interventions

Cigarette smoking remains a major public health issue. Despite a variety of treatment options, existing intervention protocols intended to support attempts to quit smoking have low success rates. An emerging treatment framework, referred to as adaptive interventions in behavioral health, addresses the chronic, relapsing nature of behavioral health disorders by tailoring the composition and dosage of intervention components to an individual's changing needs over time. An important component of a rapid and effective adaptive smoking intervention is an understanding of the behavior change relationships that govern smoking behavior and an understanding of intervention components' dynamic effects on these behavioral relationships. As traditional behavior models are static in nature, they cannot act as an effective basis for adaptive intervention design. In this article, behavioral data collected daily in a smoking cessation clinical trial is used in development of a dynamical systems model that describes smoking behavior change during cessation as a self-regulatory process. Drawing from control engineering principles, empirical models of smoking behavior are constructed to reflect this behavioral mechanism and help elucidate the case for a control-oriented approach to smoking intervention design.

Outcomes of cluster profiles within stages of change for sun protection behavior

OBJECTIVE

Predictive and external validity was studied among cluster profiles for sun protection behavior within stages from Transtheoretical Model of behavior change using follow-up data.

METHODS

Data from participants in a home-based expert system were analyzed. Longitudinal patterns of clusters on the precontemplation, contemplation, and preparation stages of change were assessed. Differences between clusters on membership in action/maintenance stages and scores on the Sun Protection Behavior Scale (SPBS) were measured at 12 and 24 months after intervention.

RESULTS

Differences between clusters on stage progression and on scores from the SPBS were found at 12 and 24 months after intervention at all stages.

DISCUSSION

Predictive and external validity of sun protection subtypes was established using sun protection variables after a stage-matched intervention. Results provide information to improve interventions for sun protection.

Teaching Brief Interventions for Smoking Cessation via an Interactive Computer-based Tutorial

Many current smokers do not plan on quitting any time soon. For these smokers, the immediate treatment goal is not a quit attempt, but an increase in readiness to stop smoking. In the present study we developed an interactive multimedia simulation and tutoring environment that teaches healthcare professionals to provide brief motivational interviewing-based smoking cessation interventions tailored to the patient's current readiness to change. This tutorial utilizes a cognitive science-derived learning approach that provides tailored feedback and lessons based on learners' pre-existing knowledge, is highly interactive and allows learners to practice skills in simulated clinical situations. Results from two pilot studies indicate that healthcare professionals and students found the software easy and enjoyable to use and successfully learned MI-based strategies for smoking cessation.

Pilot study results from a brief intervention to create smoke-free homes

Very few community-based intervention studies have examined how to effectively increase the adoption of smoke-free homes. A pilot study was conducted to test the feasibility, acceptability, and short-term outcomes of a brief, four-component intervention for promoting smoke-free home policies among low-income households. We recruited forty participants (20 smokers and 20 nonsmokers) to receive the intervention at two-week intervals. The design was a pretest-posttest with follow-up at two weeks after intervention. The primary outcome measure was self-reported presence of a total home smoking ban. At follow-up, 78% of participants reported having tried to establish a smoke-free rule in their home, with significantly more nonsmokers attempting a smoke-free home than smokers (P = .03). These attempts led to increased smoking restrictions, that is, going from no ban to a partial or total ban, or from a partial to a total ban, in 43% of the homes. At follow-up, 33% of the participants reported having made their home totally smoke-free. Additionally, smokers reported smoking fewer cigarettes per day. Results suggest that the intervention is promising and warrants a rigorous efficacy trial.

Risk groups and predictors of short-term abstinence from smoking in patients with coronary heart disease

OBJECTIVES

We sought to identify risk groups among smoking cardiac patients from their social cognitive profiles, and to assess predictors of smoking abstinence shortly after discharge.

METHODS

Smoking cardiac patients (n = 133) completed questionnaires at hospital admission and 1 month after discharge. Hierarchical cluster analysis was used to detect risk groups of smokers, based on baseline scores for smoking-related social cognitions. Regression analyses were used to identify predictors of the intention to abstain from smoking and smoking abstinence 1 month after discharge.

RESULTS

Three groups of smokers were distinguished that differed significantly on the pros of nonsmoking, self-efficacy expectancies toward nonsmoking, social support, social modeling, and smoking behavior. Abstinence from smoking 1 month after discharge was predicted by group membership and a stronger intention to quit. A previous hospital admission because of a cardiac event significantly decreased the likelihood of abstinence.

CONCLUSIONS

One third of cardiac patients are at high risk of continuing smoking after hospital discharge because of an unfavorable smoking and disease history and a poor social cognitive profile. Interventions for cardiac patients should address risk profiles to achieve long-term abstinence. The implications of nursing practices in smoking cessation treatments are discussed.

Cluster subtypes appropriate for preventing postpartum smoking relapse

OBJECTIVE

While the majority of women quit smoking either before or during pregnancy, 60 to 80% relapse in the postpartum period. The objective of this research was to examine postpartum women who quit smoking during their pregnancies and to determine the predictive factors for relapse in the postpartum period by identifying different subgroups that predict risk of relapse.

METHOD

One hundred forty four postpartum women who were abstinent at the time of delivery were recruited. Data regarding the Acquisition Stage of Change, Decisional Balance and Situational Temptations to Smoke were assessed in the immediate postpartum period. Based on their intention to remain abstinent, 121 women identified in the acquisition-Precontemplation (aPC) group comprised the study sample. Smoking status was assessed again at 2 months postpartum.

RESULTS

A cluster analysis was performed to identify subgroups of the acquisition-Precontemplation (aPC) group. Four subgroups were identified and were labeled Most Protected, Ambivalent, Risk Denial, and High Risk. Logistic regression was performed to establish external validity of the clusters. The clusters and exclusive breastfeeding were the only statistically significant variables associated with relapse at 2 months postpartum.

CONCLUSIONS

The results confirmed the clusters identified in previous prevention research with both adolescents and postpartum women, The cluster profiles can serve to guide the development of a tailored intervention program.

Identifying subtypes of dual alcohol and marijuana users: a methodological approach using cluster analysis

Alcohol is the most common psychoactive substance used with marijuana. However, little is known about the potential impact of different levels of use of both alcohol and marijuana and their influence on risky behaviors, injuries and psychosocial functioning. A systematic approach to identifying patterns of alcohol and marijuana use associated with increased risks has not yet been identified in the literature. We report on the secondary analysis of data collected from a RCT conducted in a busy urban emergency department. Cluster analysis was performed on the patterns of past 30-day alcohol and marijuana use in two random subsamples N₁=210 and N₂=217. Four distinct subtypes of those who use both alcohol and marijuana were identified: (1) Daily Marijuana and Weekly Alcohol users; (2) Weekly Alcohol and Weekly Marijuana users; (3) Daily Alcohol and Daily Marijuana users; and (4) Daily Alcohol, Weekly Marijuana users. The four subtypes were replicated in both subsamples and examination of the external validity using ANOVA to determine cluster differences on psychosocial and behavioral variables confirmed the theoretical relevance of different patterns of alcohol and marijuana use. There were significantly different psychosocial negative consequences and related risky behaviors among subtypes. We found that Daily Alcohol and Daily Marijuana users are at the highest risk to experience more negative consequences and engage in a broader spectrum of risky behaviors related to both substances, than the other three types of alcohol and marijuana users.

Cluster subtypes within the precontemplation stage of change for sun protection behavior

The aim of this study is to identify replicable cluster subtypes within the precontemplation stage of change for sun protection. Secondary data analysis of baseline data from a sample of participants in a home-based expert system intervention was performed. Three random samples were selected from participants in the precontemplation stage (N = 570). Cluster analyses were performed using the scales of pros, cons, and self-efficacy. Interpretability of pattern, pseudo F-test, and dendograms were used to determine the number of clusters. A four-cluster solution replicated across subsamples. Significant differences between clusters on the nine processes of change and on behavioral measures were found. Cluster solutions were robust, interpretable and with good initial external validity. They replicated patterns found for other behaviors, demonstrating long-term predictability and providing basis for tailored interventions.

Motivational profiles of clients seeking methadone maintenance therapy in China

OBJECTIVE

This study applied a stage-of-change model to examine the motivational profiles of clients seeking methadone maintenance therapy (MMT) in China.

METHODS

Face-to-face interviews were conducted with a total of 179 clients from six MMT clinics. The University of Rhode Island Change Assessment (URICA) scale was used to measure the participants' motivation and readiness to change. Cluster analysis was performed to classify the sample into subgroups with respect to their change dimensions.

RESULTS

The study sample was allocated into five distinct clusters: uninvolved, denial, pre-participation, ambivalent, and participation. Participants who were classified in the denial cluster were older than those in the pre-participation and participation clusters. A higher level of motivation to change was positively associated with continued heroin use and more severe drug problems.

DISCUSSION

It would be beneficial to evaluate motivational profiles of individual clients in the treatment planning process and provide tailored interventions for sustained treatment retention and outcomes.

Special diabetes program for Indians: retention in cardiovascular risk reduction

PURPOSE

This study examined the associations between participant and site characteristics and retention in a multisite cardiovascular disease risk reduction project.

DESIGN AND METHODS

Data were derived from the Special Diabetes Program for Indians Healthy Heart Demonstration Project, an intervention to reduce cardiovascular risk among American Indians and Alaska Natives with diabetes. In 2006, a total of 1,072 participants from 30 participating sites completed baseline questionnaires measuring demographics and sociobehavioral factors. They also underwent a medical examination at baseline and were reassessed annually after baseline. A Provider Annual Questionnaire was administered to staff members of each grantee site at the end of each year to assess site characteristics. Generalized estimating equation models were used to evaluate the relationships between participant and site characteristics and retention 1 year after baseline.

RESULTS

Among enrolled participants, 792 (74%) completed their first annual assessment. Participants who completed the first annual assessment tended to be older and had, at baseline, higher body mass index and higher level of physical activity. Site characteristics associated with retention included average age of staff, proportion of female staff members, and percentage of staff members having completed graduate or professional school.

IMPLICATIONS

Understanding successful retention must reach beyond individual characteristics of participants to include features of the settings that house the interventions.

Subtypes of smokers who attend psychological treatment in order to stop smoking

The aim of this study is to identify subtypes of smokers who attended psychological treatment during the period 2006-2008 for smoking cessation from a sample of current smokers (N = 202) from Galicia, Spain. Eight instruments were used for data collection. Demographic variables, smoking variables, and psychopathological characteristics were clustered to establish typologies of smokers. A two-phase cluster analysis identified two subtypes of smokers (141 in Cluster 1 and 61 in Cluster 2). Those in Cluster 2 were younger, and had made an attempt to quit in the last year. They presented higher levels of nicotine dependence and psychopathology than those in Cluster 1. Differences in nicotine withdrawal syndrome, cigarette consumption at the end of the treatment, and adherence to the treatment were significant across the two clusters.

Smoking cessation during pregnancy: the influence of partners, family and friends on quitters and non-quitters

This research compared pregnant quitters' and non-quitters' accounts of how partners, family and friends influenced their smoking cessation attempts. Qualitative secondary data analysis was carried out on a purposive sample of motivational interview transcripts undertaken by research midwives with pregnant women as part of SmokeChange, a smoking cessation intervention. Interviews with all quitters in the intervention group (n = 12) were analysed comparatively with interviews from a matched sample of non-quitters (n = 12).The discourses of both revealed similarity in how their partners, family and friends influenced their cessation efforts: salient others were simultaneously perceived by both groups of women as providing drivers and barriers to quit attempts; close associates who smoked were often perceived to be as supportive as those who did not. However, women who quit smoking during pregnancy talked more about receiving active praise/encouragement than those who did not. While close associates play an important role in women's attempts to stop smoking during pregnancy, the support they provide varies; further research is needed to develop a better understanding of how key relationships help or hinder cessation during pregnancy.

Inconsistent mammography perceptions and practices among women at risk of breast cancer following a pediatric malignancy: a report from the Childhood Cancer Survivor Study

Women treated with chest radiation for a pediatric cancer have low mammography screening rates despite their high risk for breast cancer. This study characterized the relationship between perceptions of mammography and screening practices. A cross-sectional survey was administered to 523 women in North America who were treated with chest radiation before 21 years of age. Women with inconsistent mammography perceptions and practices were identified using the Pros and Cons of Mammography for perceptions and Transtheoretical Model stages of adoption for prior and intended screening practices. Classification and regression tree (CART) analysis was used to identify barriers to and facilitators of screening among women with positive and negative perceptions. Nearly one-third of the cohort had inconsistent perceptions and practices: 37.4% had positive perceptions and were not having mammograms; 27.6% had negative/neutral perceptions and were having mammograms. Regardless of perceptions, a recent physician's recommendation for mammography, age ≥ 40, and interest in routine health care were universally associated with mammography practices. For women with positive perceptions and a physician's recommendation, barriers to screening included high acceptance coping, low active-planning coping, and high internal health locus of control. For women with negative perceptions, acknowledging the importance of asymptomatic screening was associated with mammography.

Motivation and Autonomy in Counseling, Psychotherapy, and Behavior Change: A Look at Theory and Practice 1ψ7

Motivation has received increasing attention across counseling approaches, presumably because clients’ motivation is key for treatment effectiveness. The authors define motivation using a self-determination theory taxonomy that conceptualizes motivation along a relative-autonomy continuum. The authors apply the taxonomy in discussing how various counseling approaches address client motivation and autonomy, both in theory and in practice. The authors also consider the motivational implications of nonspecific factors such as therapeutic alliance. Across approaches, the authors find convergence around the idea that clients’ autonomy should be respected and collaborative engagement fostered. The authors also address ethical considerations regarding respect for autonomy and relations of autonomy to multicultural counseling. The authors conclude that supporting autonomy is differentially grounded in theories and differentially implemented in approaches. Specifically, outcome-oriented treatments tend to consider motivation a prerequisite for treatment and emphasize transparency and up-front consent; process-oriented treatments tend to consider motivation a treatment aspect and give less emphasis to transparency and consent.

Does a typical contemplator exist? Three clusters of smokers in contemplation

The aim of this study is to test whether subtypes exist among smokers in contemplation. Data from 194 adult smokers that participated in a randomized controlled trial testing the effectiveness of a computer-tailored smoking cessation program in Dutch general practices were used for secondary analysis. Cluster analysis was conducted based on baseline scores on pros and cons of quitting and self-efficacy to quit. Clusters were cross-sectionally compared for demographic variables and smoking characteristics with analyses of variance (ANOVA) and Chi-square tests. Logistic and multinomial regression analyses were used for longitudinal comparison for smoking behavior and stage of change at 6 months follow-up. Three clusters were identified: Early, Progressing and Disengaged Contemplators. Clusters differed significantly on all clustering variables (P < 0.001). Disengaged smokers were significantly less addicted than Early Contemplators. Cluster membership was not predictive of outcome measures. No subtype was identified representing the Classic Contemplator, scoring high on both pros and cons of quitting and low on self-efficacy, as found in previous studies among US samples. The predictive validity of the clusters found was limited.

Testing the predictive power of the transtheoretical model of behavior change applied to dietary fat intake

This study evaluated how well predictions from the transtheoretical model (TTM) generalized from smoking to diet. Longitudinal data were used from a randomized control trial on reducing dietary fat consumption in adults (n =1207) recruited from primary care practices. Predictive power was evaluated by making a priori predictions of the magnitude of change expected in the TTM constructs of temptation, pros and cons, and 10 processes of change when an individual transitions between the stages of change. Generalizability was evaluated by testing predictions based on smoking data. Three sets of predictions were made for each stage: Precontemplation (PC), Contemplation (C) and Preparation (PR) based on stage transition categories of no progress, progress and regression determined by stage at baseline versus stage at the 12-month follow-up. Univariate analysis of variance between stage transition groups was used to calculate the effect size [omega squared (omega(2))]. For diet predictions based on diet data, there was a high degree of confirmation: 92%, 95% and 92% for PC, C and PR, respectively. For diet predictions based on smoking data, 77%, 79% and 85% were confirmed, respectively, suggesting a moderate degree of generalizability. This study revised effect size estimates for future theory testing on the TTM applied to dietary fat.

Translating research on healthy lifestyles for children: meeting the needs of diverse populations

This article provides two examples of approaches nursing can take to reach diverse populations of children and their families to enhance health lifestyles. First, a descriptive summary of a brief after-school intervention program aimed at influencing 8- and 9-year-old children's media habits and the prevention of negative health behaviors is presented. Design consideration for translating health lifestyles research findings into a nurse-managed inner city primary care practice is reviewed in the second example.

A Review of Men's Health and Masculinity

Men's health is a new and evolving area of specialty that goes beyond men's cancers and sexual activities. Men's health in the 21st century incorporates a broader conceptualization of health, health behaviors, and lifestyle choices. This new focus results from the fact that men continue to lag behind women in life expectancy and in health care use, a situation that is worse for minority men. Understanding how gender socialization and masculine ideology affects men's health is an important step toward providing effective care for men. In this article, the authors review these areas and then discuss each of the top actual causes of death for men: tobacco use, poor diet, alcohol use, and physical inactivity. They then discuss the important issue of steroid use among men. Throughout the review, the authors highlight racial and ethnic differences in health behaviors. Furthermore, they provide empirically supported clinical implications to assist clinicians who see men with health concerns in their practices. Finally, they offer suggestions for creating ways to include men in the health care system in hopes of improving their use.

The 2005 British Columbia smoking cessation mass media campaign and short-term changes in smokers attitudes

The effect of the 2005 British Columbia (BC) smoking cessation mass media campaign on a panel (N = 1,341) of 20-30-year-old smokers' attitudes is evaluated. The 5-week campaign consisted of posters, television, and radio ads about the health benefits of cessation. Small impacts on the panel's attitudes toward the adverse impacts of smoking were found, with greater impacts found for those who had no plans to quit smoking at the initial interview. As smokers with no plans to quit increasingly recognized the adverse impacts of smoking, they also increasingly agreed that they use smoking as a coping mechanism. Smokers with plans to quit at the initial interview already were well aware of smoking's adverse impacts. Respondents recalling the campaign poster, which presented a healthy alternative to smoking, decreased their perception of smoking as a coping mechanism and devalued their attachment to smoking. Evidence was found that media ad recall mediates unobserved predictors of attitudes toward smoking.

Delay of first treatment of mental and substance use disorders in Mexico

OBJECTIVES

We studied failure and delay in making initial treatment contact after the first onset of a mental or substance use disorder in Mexico as a first step to understanding barriers to providing effective treatment in Mexico.

METHODS

Data were from the Mexican National Comorbidity Survey (2001-2002), a representative, face-to-face household survey of urban residents aged 18 to 65 years. The age of onset for disorders was compared with the age of first professional treatment contact for each lifetime disorder (as defined by the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition).

RESULTS

Many people with lifetime disorders eventually made treatment contact, although the proportions varied for mood (69.9%), anxiety (53.2%), and substance use (22.1%) disorders. Delays were long: 10 years for substance use disorders, 14 years for mood disorders, and 30 years for anxiety disorders. Failure and delay in making initial treatment contact were associated with earlier ages of disorder onset and being in older cohorts.

CONCLUSIONS

Failure to make prompt initial treatment contact is an important reason explaining why there are unmet needs for mental health care in Mexico. Meeting these needs will likely require expansion and optimal allocation of resources as well as other interventions.

Enhancing regular physical activity and relapse prevention through a 1-day therapeutic patient education workshop: A pilot study

OBJECTIVE

Physical activity (PA) is important for managing chronic diseases, such as diabetes and obesity. Yet over half of patients who adopt PA programs do not maintain them at 6 months. To encourage regular PA among our patients, we developed a 1-day outpatient motivational workshop based on well-known theoretical frameworks. The purpose of this pilot study was to evaluate the effectiveness of the motivational workshop in terms of total and activity-specific energy expenditures (EE) and body mass index (BMI).

METHODS

This workshop is an integrative model of multiple theoretical frameworks for therapeutic education and behavior change, alternating individual sessions and group sessions in a multidisciplinary setting. Patients completed a validated, self-administered, quantitative PA frequency questionnaire at baseline and at 1 year. Stages of change and relapse risk were identified at baseline.

RESULTS

Twenty-five subjects, mean age 48 years and BMI 34.1kg/m(2), completed pre-/post-evaluations. At baseline, 73% of subjects reported regular activities of daily living and 52% reported regular formal exercise. Using total and activity-specificEE, we identified 69.2% as sedentary. A relapse risk was recognized in 76%. Paired t-tests showed significant (P=0.048) reductions in weight and BMI and a significant (P=0.015) increase in high-intensity exerciseEE. Total EE showed no difference. Among baseline sedentary subjects, 39% became active.

CONCLUSION

This workshop may be effective in modifying PA patterns, thereby decreasing sedentarism and fostering PA maintenance.

PRACTICE IMPLICATIONS

The theory-based workshop for increasing motivation to maintain optimal PA behavior provides an example of translational intervention from theoretical models to clinical practice.

Identifying cluster subtypes for the prevention of adolescent smoking acquisition

School-based smoking prevention programs are typically identical for all students. Tailoring prevention materials to focus on individual needs with an emphasis on students at highest risk is a promising alternative. Recent prevention programs have tailored materials based on the Stages of Acquisition, an extension of the Stages of Change used to tailor smoking cessation materials effectively for adults. Three stages of acquisition have been identified: Acquisition Precontemplation (aPC), Acquisition Contemplation (aC) and Acquisition Preparation (aPR). However, about 90% of nonsmoking adolescents classify themselves in the aPC stage. A cluster analysis was performed, using the Decisional Balance and Situational Temptations scales, for three random subsamples of adolescents within the aPC stage (N(1)=N(2)=N(3)=514). Four distinct subtypes were identified in each subsample: High Risk, Protected, Ambivalent, and Risk Denial. External validity was established using family support for nonsmoking, peer variables, and stage classification at follow-up assessment (12, 24, and 36 months). Family support for nonsmoking was related to subtype much more strongly than peer interactions. Subjects in the Protected subgroup were the most likely to remain in the aPC stage at each follow-up assessment. Subtype membership, along with membership in the aC and aPR stages, provides important additional information for tailoring smoking prevention materials. Tailored interventions can focus on those adolescents at highest risk and limit or avoid expending resources on those at very low risk.

Lung cancer screening as a teachable moment for smoking cessation

BACKGROUND

Lung cancer screening may serve as a 'teachable moment' for smoking cessation, a brief period in which motivation to stop smoking is enhanced. Within the context of two NCI-funded randomized lung screening trials, we conducted an ancillary study to explore the impact of screening on smoking cessation and readiness to stop smoking.

METHODS

We accrued a sample of current and former smokers participating at the Georgetown University site of the Lung Screening Study (LSS; N=144) and of the National Lung Screening Trial (NLST; N=169). In each sample, we assessed reasons for trial participation, interest in smoking cessation interventions, motivations for stopping smoking, and the impact of undergoing screening on tobacco use and readiness to stop smoking. Telephone interviews were conducted prior to screening, and 1-month following receipt of the screening result. The samples were analyzed separately due to differences in age and level of nicotine dependence.

RESULTS

The majority of the findings were consistent across the two samples. Frequently endorsed reasons for trial participation among both current and former smokers included psychological reasons (e.g., wanting peace of mind about lung cancer) and altruism (e.g., wanting to make a contribution to science). Nicotine replacement therapy and free counseling were the cessation methods that were of most interest, and fear of lung health problems was the most frequently endorsed motivation for quitting smoking. Regarding readiness to stop smoking, approximately 20% were ready to stop in the next 30 days, 45% were ready to stop in the next 6 months, while 35% were not thinking of stopping. At the follow-up, 7% of current smokers at baseline reported abstinence, and 4% of former smokers at baseline reported having relapsed. The findings differed across the two samples when considering the readiness to quit outcome. At the 1-month follow-up of the NLST sample, participants became more ready to stop smoking (p<.05). Screening result did not moderate this finding. In the LSS sample, among younger participants (<or=64), an abnormal screening result was significantly associated with becoming more ready to stop smoking, whereas a normal result was associated with becoming less ready to stop smoking (p=.02).

CONCLUSIONS

The current findings demonstrated the feasibility of enrolling lung screening participants into a smoking-related research study, as well as the high level of interest in stopping smoking and in smoking cessation interventions. These data indicate that lung cancer screening may serve as a teachable moment for smoking cessation, and suggest that a smoking cessation trial within the context of lung cancer screening is feasible.

The perceived advantages and disadvantages of presymptomatic testing for Machado-Joseph disease: development of a new self-response inventory

This study describes the construction of a self-response inventory to evaluate the perception of advantages and disadvantages of the Machado-Joseph disease presymptomatic testing, in 44 individuals at-risk for this disease. The results showed that the reliability of this inventory was satisfactory. Factor analysis revealed a bidimensional structure: perceived advantages (pros) and perceived disadvantages (cons) of presymptomatic testing. Social desirability was found unrelated to the total scores of our inventory. Additional correlation studies, with other scales, confirmed the convergent validity of the instrument. These results suggest adequate construct validity. This inventory thus seems to be a proper instrument to assess expectations involved in the decision-making process of Machado-Joseph disease presymptomatic testing.

Prevention profiles: Understanding youth who do not use substances

This study replicates innovative profiles of prevention among students not using substances but who may be at different risks for acquisition. Using the Transtheoretical Model constructs of Decisional Balance and Temptations, cluster analyses were performed on four independent samples of students (n=1240) in the USA, England and Israel. For each sample, the same four distinct profiles emerged. ANOVAs indicated that the processes of prevention varied significantly across these profiles. The prevention profiles were extended to youth in Elementary, Middle, and High Schools and from a focus on single substances to multiple substances, including alcohol, tobacco, and illicit drugs. Implications for developing prevention programs are also discussed.

Replication of subtypes for smoking cessation within the precontemplation stage of change

The Transtheoretical Model constructs have been used in the development of effective tailored interventions for smoking cessation. Recent studies have suggested the existence of clusters within each stage of change, based on measures of the Pros, Cons and the Situational Temptations. The goal of this study is to replicate cluster subtypes within the Precontemplation stage of change in a secondary analysis of data from a sample of current smokers (N=3967). Four random samples ranging from 312 to 400 participants were selected from the Precontemplators subgroup. The cluster analyses were performed using Ward's Method on the standard scores from the three scales. Interpretability of the pattern, pseudo F test, and dendograms were used to determine the number of clusters. Four cluster subtypes were found and replicated across samples. The ten processes of change and two smoking behavior variables were used in the external validation of clusters. Statistically significant multivariate effects were found for the processes of change (p<.05) and the smoking behavior variables (p<.001) in all samples. The cluster patterns closely replicate earlier findings and provide evidence for the existence of clusters subtypes within the Precontemplation stage of change.

A Phase II study of St. John's Wort for smoking cessation

OBJECTIVES

To examine the feasibility and efficacy of St. John's Wort (SJW) for smoking cessation.

DESIGN

This one-arm Phase II study utilized an exact two-stage group sequential design with a 1-week run-in period between the start of SJW treatment and the designated quit date. A total of 37 smokers (ages 18-65 years, smoking > or = 10 cigarettes/day) were started on SJW. Thirteen failed to make a verified quit attempt on the predesignated date and were taken off study resulting in 24 evaluable subjects.

SETTING

Smokers completed clinic visits at a cancer center with interval telephone calls and mailings.

INTERVENTION

Standardized SJW, 450 mg capsules taken orally twice daily along with cessation counseling messages.

MAIN OUTCOME MEASURES

Subjects completed validated surveys and a focused physical examination at baseline. Evaluable subjects were defined as those subjects who made a confirmed quit attempt on their "quit date" 1 week following initiation of SJW. Smoking status was determined through self-report and bioverification using carbon monoxide (CO) testing.

RESULTS

Among evaluable subjects, the 12-week quit rate was 37.5% (9/24). Quitters had no significant change in weight from baseline to 12-weeks cessation. Use of SJW was generally well tolerated.

CONCLUSIONS

Based upon these results (which suggest that SJW may be effective in maintaining smoking cessation) and the high compliance and few AEs, we conclude that SJW demonstrates feasibility for use in smoking cessation. If SJW proves to be effective in larger controlled studies, it could represent a less expensive, more readily accessible and well-tolerated agent to promote tobacco cessation.

Replication of subtypes for smoking cessation within the Preparation stage of change

OBJECTIVE

Recent cluster analyses based on the Pros and Cons and the Situational Temptations measures performed within the stages of change defined by the Transtheoretical Model have suggested the existence of distinct cluster subtypes. The goal of this study is to replicate cluster subtypes within the Preparation stage of change in a secondary analysis of data from a sample of current smokers (N=3967). Identification of stable cluster subtypes would permit the development of tailored interventions focusing on these subtypes.

METHOD

Two random samples of approximately 340 subjects were selected from the 686 participants in the Preparation stage. The cluster analyses were performed using the Pros, Cons and Situational Temptations. Interpretability of the pattern, pseudo F test, and dendograms were used to determine the number of clusters.

RESULTS

Four distinct cluster subtypes (Classic, Progressing, Early Preparation, and Disengaged) were found and replicated across samples. The clusters were externally validated using the ten processes of change and two smoking behavior variables. Statistically significant (p<0.05) multivariate effects were found for the ten processes of change and the smoking behavior variables (p<0.001) in the two samples.

CONCLUSIONS

The cluster patterns replicate earlier findings and provide evidence for the existence of clusters subtypes within the Preparation stage of change.

Implementing a Multidisease Chronic Care Model in Primary Care Using People and Technology

Management of chronic disease is performed inadequately in the United States in spite of the availability of beneficial, effective therapies. Successful programs to manage patients with these diseases must overcome multiple challenges, including the recognized fragmentation and complexity of the healthcare system, misaligned incentives, a focus on acute problems, and a lack of team-based care. In many successful programs, care is provided in settings or episodes that focus on a single disease. While these programs may allow for streamlined, focused provision of care, comprehensive care for multiple diseases may be more difficult. At Intermountain Healthcare (Intermountain), a generalist model of chronic disease management was formulated to overcome the limitations associated with specialization. In the Intermountain approach, which reflects elements of the Chronic Care Model (CCM), care managers located within multipayer primary care clinics collaborate with physicians, patients, and other members of a primary care team to improve patient outcomes for a variety of conditions. An important part of the intervention is widespread use of an electronic health record (EHR). This EHR provides flexible access to clinical data, individualized decision support designed to encourage best practice for patients with a variety of diseases (including co-occurring ones), and convenient communication between providers. This generalized model is used to treat diverse patients with disparate and coexisting chronic conditions. Early results from the application of this model show improved patient outcomes and improved physician productivity. Success factors, challenges, and obstacles in implementing the model are discussed.