Bridging Culture and Language: Encouraging Bilingual/Multicultural Individuals to Act as Information Navigators for Their Loved-Ones and Communities during the COVID-19 Pandemic

Linguistically diverse communities face barriers to receiving appropriate health information. COVID-19 exacerbated these health-communication inequities. University of Washington researchers surveyed bilingual staff, students, and medical interpreters - desiring training to become effective communicators of COVID-19 information to their social networks and language communities. In response, the COVID-19 Information Navigator Training was developed and pre-tested with professional networks and members of the target audience. The final training comprised three interactive modules and short quizzes. Evaluation surveys measured Information Navigators' confidence in providing COVID-19 information to their social networks. Surveys included questions on the participants' language or cultural community, the perceived value of the training, and their ability to communicate COVID-19 information. Among 393 participants who enrolled in the training, 284 completed the survey. Significant differences in confidence before and after the course were found in detecting COVID misinformation in the news and social media (pre-course mean: 3.83, post-course mean: 4.63; absolute mean difference was 0.82 points higher in the post-evaluation on the 5-point likert scale, 95% CI: 0.70-0.93, p < .01). Training multicultural volunteers to disseminate information to their social networks is a promising strategy for reaching linguistically diverse communities with up-to-date information during health emergencies.

Effect of Mandatory and Voluntary Overtime Hours on Stress Among 9-1-1 Telecommunicators

BACKGROUND

9-1-1 telecommunicators are frequently exposed to indirect traumatic events that impact their mental and physical health and are often required to work overtime with rotating shifts. Previous studies reported various harmful effects of overtime on the health and well-being of workers, such as musculoskeletal injuries, burnout, low job satisfaction, fatigue, and intent to leave. However, there is limited research on the impact of overtime hours on 9-1-1 telecommunicators' stress symptoms, especially mandatory overtime hours. This study aimed to examine the relationship between overtime hours-mandatory and voluntary-and the level of stress symptoms among 9-1-1 telecommunicators.

METHODS

We used secondary data from the surveys of the "Multi-tasking to hyper-tasking: Investigating the impact of Next Generation 9-1-1" study for analysis. Linear mixed-effects regression was applied to examine the association of overtime hours with the stress level.

RESULTS

Of the 403 participants, 47.6% reported that they were required to work mandatory overtime, and the mean mandatory overtime was 7.51 (SD = 12.78) hours in the past month. 58.3% reported working voluntary overtime, and the mean voluntary overtime was 11.63 (SD = 17.48) hours. This study found that mandatory overtime hours were associated with an increase in self-reported stress symptoms (β = 0.30, p = .002), whereas no significant association was found between voluntary overtime and the level of stress symptoms (β = -0.01, p = .885).

CONCLUSION/APPLICATION TO PRACTICE

Study results highlight the importance of reducing mandatory overtime in call centers as one possible strategy for reducing stress levels among this critical workforce.

"Another tool in the toolkit"-Perceptions, suggestions, and concerns of emergency service providers about the implementation of a supervised consumption site

BACKGROUND

As Supervised Consumption Sites (SCS) are implemented in the United States, it is important to consider the needs and perceptions of impacted stakeholders. Emergency service providers (ESP) have a central role in responding to the overdose epidemic. This study intended to assess the how ESP perceive the potential implementation of an SCS in their community, as well as solicit program design and implementation-related concerns and suggestions.

METHODS

In-depth interviews were conducted by videoconference with 22 ESP, including firefighters, paramedics, police, and social workers in King County, Washington, USA. Data were analyzed using a thematic analysis approach.

RESULTS

Participants expressed the importance of feeling safe while responding to calls where drug use is involved and highlighted how this perception would be linked to ESP response times to calls from an SCS. Suggestions for improving the perceived safety of an SCS included training program staff in de-escalation as well as planning the layout of the SCS to accommodate ESP. The inadequacy of the emergency department as a point of care for PWUD was also identified as a theme, and some participants expressed enthusiasm regarding the prospect of the SCS as an alternative destination for transport. Finally, support for the SCS model was conditional on the appropriate utilization of emergency services and a reduction in call volume. Participants listed clarifying roles and pursuing opportunities for collaboration as ways to ensure appropriate utilization and maintain positive working relationships.

CONCLUSION

This study builds on literature regarding stakeholder perceptions of SCS by focusing on the perceptions of a critically important stakeholder group. Results enhance understanding of what motivates ESP to support SCS implementation in their community. Other novel insights pertain to ESP thoughts about alternative care delivery models and strategies for emergency department visit diversion.

Development and Evaluation of an Online Toolkit for Managers of 9-1-1 Emergency Communications Centers to Reduce Occupational Stress

This article describes the development and evaluation of an online workplace stress reduction toolkit for use by managers of 9-1-1 emergency communication centers (ECCs). A three-step process for development and testing of digital learning resources was used: (1) establishing need and focus through ECC manager stakeholder engagement, (2) pretesting of the toolkit with the target ECC manager audience, and (3) toolkit utilization and evaluation. The toolkit was developed in close partnership with stakeholders throughout the entire process. Toolkit usage was documented via registration data. The evaluation utilized an online survey that included closed and open-ended questions, which were analyzed using descriptive statistics and qualitative thematic analysis. Over a 20-month period, 274 people registered for the toolkit and, of those, 184 (67%) accessed the content. Respondents to the evaluation survey (N = 156) scored the toolkit highly on satisfaction, self-efficacy, and perceived utility measures. Survey respondents reported intent to apply toolkit content through the following: providing organizational resources to help workers take better care of themselves (41%); creating a lower stress worksite environment (35%) and sharing resources with staff to (1) reduce stress (19%), (2) support conflict resolution (21%), and (3) prevent and/or stop bullying (17%). In delivering actionable content to ECC managers, the toolkit shows promise in addressing and mitigating occupational stress in ECCs. Further research needs to determine the relationship of this strategy for reducing ECC stress.

"[T]he laws need to change to reflect current society": Insights from stakeholders involved in development, review or implementation of policies about adolescent consent for HIV testing, care and research in Kenya

INTRODUCTION

Engaging adolescents in HIV care and research promotes the development of interventions tailored to their unique needs. Guidelines generally require parental permission for adolescents to receive HIV care/testing or participate in research, with exceptions. Nevertheless, parental permission requirements can restrict adolescent involvement in care and research. To better appreciate prospects for policy reform, we sought to understand the perspectives of stakeholders involved in the development, review and implementation of policies related to adolescents living with HIV.

METHODS

Semi-structured individual interviews (IDIs) were conducted from October 2019 to March 2020 with 18 stakeholders with expertise in the (1) development of policy through membership in the Law Society of Kenya or work as a health policy official; (2) review of policy through ethics review committee service; or (3) implementation of policy through involvement in adolescent education. IDIs were conducted in English by Kenyan social scientists, audio-recorded and transcribed verbatim. We used thematic analysis to identify themes around how policies can be reformed to improve adolescent engagement in HIV care and research.

RESULTS

Our analysis identified three major themes. First, policies should be flexible rather than setting an age of consent. Stakeholders noted that adolescents' capacity for engagement in HIV care and research depended on context, perceived risks and benefits, and "maturity"-and that age was a poor proxy for the ability to understand. Second, policies should evolve with changing societal views about adolescent autonomy. Participants recognized a generational shift in how adolescents learn and mature, suggesting the need for a more frequent review of HIV care and research guidelines. Third, adults should empower adolescent decision-making. Stakeholders felt that caregivers can gradually involve adolescents in decision-making to equip them to gain ownership over their health and lives, improving their confidence and capacity.

CONCLUSIONS

Revising relevant laws to consider context, alternative measures of maturity, and evolving societal views about adolescence, along with supporting caregivers to assist in developing adolescent autonomy may promote more equitable and representative participation of adolescents in HIV care and research. Additional research should explore how to support caregivers and other adults to empower adolescents and improve stakeholder engagement in a more routine process of policy reform.

Perceptions of Prehospital Care for Patients With Limited English Proficiency Among Emergency Medical Technicians and Paramedics

IMPORTANCE

Patients with limited English proficiency (LEP) experience disparities in prehospital care. On-scene interactions between patients with LEP and emergency medical services (EMS) providers (ie, firefighters/emergency medical technicians [EMTs] and paramedics) are critical to high-quality care and have been minimally explored.

OBJECTIVE

To identify EMS-perceived barriers and facilitators to providing high-quality prehospital care for patients with LEP.

DESIGN, SETTING, AND PARTICIPANTS

In this qualitative study, semi-structured focus groups were conducted with firefighters/EMTs and paramedics with all levels of experience from urban areas with a high proportion of residents with LEP from July to September 2018. Data were analyzed from July 2018 to May 2019.

EXPOSURES

Providing prehospital care for patients with LEP.

MAIN OUTCOMES AND MEASURES

The main outcomes were barriers and facilitators to prehospital care for patients with LEP, assessed using thematic analysis. Four domains of interest were examined: (1) overall impressions of interactions with patients with LEP, (2) barriers and facilitators to communication, (3) barriers and facilitators to providing care, and (4) ideas for improving prehospital care for patients with LEP.

RESULTS

Thirty-nine EMS providers participated in 8 focus groups: 26 firefighters/EMTs (66%) and 13 paramedics (33%). The median age of participants was 46 years (range, 23-63 years), and 35 (90%) were male. Participants described barriers to optimal care as ineffective interpretation, cultural differences, high-stress scenarios (eg, violent events), unclear acuity of patient's condition, provider bias, and distrust of EMS. Perceived facilitators to optimal care included using an on-scene interpreter, high-acuity disease, relying on objective clinical findings, building trust and rapport, and conservative decision-making regarding treatment and transport. Providers reported transporting most patients with LEP to hospitals regardless of illness severity due to concern for miscommunication and unrecognized problems. Better speed and technology for interpretation, education for communities and EMS providers, and community-EMS interactions outside emergencies were cited as potential strategies for improvement.

CONCLUSIONS AND RELEVANCE

In this study, EMS providers described many barriers to high-quality care during prehospital emergency response for patients with LEP yet were unaware that these barriers impacted quality of care. Barriers including ineffective interpretation, provider bias, distrust of EMS, and cultural differences may contribute to outcome disparities and overutilization of resources. Future work should focus on the development of targeted interventions to improve modifiable barriers to care, such as improving interpretation and cultural humility and increasing trust.

The impact of medical tourism on cervical cancer screening among immigrant women in the U.S

Background

Research on the relationship between medical tourism—traveling abroad for healthcare and cervical cancer screening is lacking. This study examines (1) the association between medical tourism and cervical cancer screening among immigrant women and (2) whether the association varies across years in the U.S.

Methods

We analyzed the New Immigrant Survey data of immigrant women aged 21–65 (n = 999). The outcome was having had a Pap smear since becoming a permanent resident, and the main predictor was medical tourism. Logistic regressions were conducted.

Results

Immigrant women who engaged in medical tourism had higher cervical cancer screening rates compared to those who did not engage in medical tourism (84.09% vs. 71.68%). This relationship was statistically significant only among women who have recently immigrated, after controlling for covariates.

Conclusions

Immigrant women who engaged in medical tourism had 2.18 higher odds of receiving a Pap smear than immigrant women who did not, after controlling for other covariates. Health educators should be aware of the practice of medical tourism and consider providing education on adherence to cancer screening guidelines and follow up abnormal results to ensure that immigrant women receive continuous cancer care.

A Revised Ecological Model of Occupational Stress: Applications to 9-1-1 Telecommunicators

Background: A cohesive body of scientific evidence has documented the adverse impacts of occupational stress on worker health and safety and, to a lesser extent, on organizational outcomes. How such adverse impacts may be prevented and/or ameliorated are important to understand, but progress has been limited due to the lack of a robust and comprehensive theoretical model of occupational stress. Methods: Building on a review of existing theoretical models of occupational stress and an ecological framework, a multilevel conceptual model of occupational stress and strain is proposed that identifies various and potentially interacting sources of occupational stressors as well as potential protective factors. Results: The revised ecological model proposed herein embraces a broad conceptualization of outcomes and includes an individual worker, work unit (team) performance as well as organizational level outcomes; for example, resilience/dysfunction. Conclusion/Application to Practice: This model provides occupational health nurses with an improved understanding of occupational and worker health as well as guidance in developing targeted interventions and generating new lines of occupational stress research.

Finding Dr. Kim: Information Sources of Korean Immigrants' Search for a Doctor in the U.S

Korean immigrants in the United States (U.S.) are known for their preference for, and dependence on, co-ethnic doctors due to various barriers to the U.S. healthcare system. Recent immigrants tend to face more barriers than their non-recent counterparts. However, there is little information on how they find their doctors in the U.S. This study includes a self-administrated survey of Korean immigrants aged 18 and above who lived in the New York-New Jersey Metropolitan area in 2013-2014 (n = 440). Descriptive analysis was conducted to understand the most common information sources and the number of sources based on the duration of stay in the U.S. More recent Korean immigrants were female, had no family doctor, uninsured, younger, and more educated than their non-recent counterparts. Regardless of the duration of stay in the U.S., family members and friends were the most frequently sought-after sources for Korean immigrants in their search for doctors. In addition to family members and friends, non-recent Korean immigrants also used other methods (e.g., Korean business directories), whereas recent immigrants used both U.S. and Korean websites. More recent Korean immigrants used multiple sources compared to non-recent Korean immigrants, often combined with a Korean website. Our study suggests policy implications to improve recent immigrants' accessibility to health information in a timely manner.

Factors Associated with Buying Medications Abroad by Nativity and Race/Ethnicity in the US

Growing costs of prescription medication are leading to increased purchases of prescriptions abroad. Yet there is a research gap of factors associated with this practice by nativity and race/ethnicity. We analyzed the 2017 National Health Interview Survey (n = 26,488). The outcome was whether the respondent purchased prescription medications from another country to save money in the past 12 months. Predictors were drawn from Andersen's healthcare utilization model. We used logistic regression models to examine factors associated with purchases by nativity and race/ethnicity. Foreign-born and Hispanic respondents showed a higher rate of purchasing medications abroad compared to their US-born and non-Hispanic white counterparts. Foreign-born respondents who are uninsured, who have no usual place of healthcare, who have difficulty finding a doctor, and who have lived in the US for less than 10 years were more likely to buy medications abroad. Different racial/ethnic groups differed on associated enabling factors. Need factor was significantly associated only with Hispanics' purchase of medications abroad. Our research reveals the need for health education regarding the safety and the illegality of this behavior, especially among recent and Hispanic immigrants.

Participant Engagement in and Perspectives on a Web-Based Mindfulness Intervention for 9-1-1 Telecommunicators: Multimethod Study

Background

Demanding working conditions and secondary exposure to trauma may contribute to a high burden of stress among 9-1-1 telecommunicators, decreasing their ability to work effectively and efficiently. Web-based mindfulness-based interventions (MBIs) can be effective in reducing stress in similar populations. However, low engagement may limit the effectiveness of the intervention.

Objective

The aim of this study was to assess participant engagement in a Web-based MBI designed for 9-1-1 telecommunicators. Specifically, we sought to describe the following: (1) participant characteristics associated with intervention engagement, (2) participant perspectives on engaging with the intervention, and (3) perceived challenges and facilitators to engaging.

Methods

We used qualitative and quantitative data from participant surveys (n=149) that were collected to assess the efficacy of the intervention. We conducted descriptive and bivariate analyses to identify associations between demographic, psychosocial, and workplace characteristics and engagement. We conducted a thematic analysis of qualitative survey responses to describe participant experiences with the MBI.

Results

We found that no individual participant characteristics were associated with the level of engagement (low vs high number of lessons completed). Participant engagement did vary by the call center (P<.001). We identified the following overarching qualitative themes: (1) the participants perceived benefits of mindfulness practice, (2) the participants perceived challenges to engage with mindfulness and the intervention, and (3) intervention components that facilitated engagement. The participants expressed positive beliefs in the perceived benefits of practicing mindfulness, including increased self-efficacy in coping with stressors and increased empathy with callers. The most commonly cited barriers were work-related, particularly not having time to participate in the intervention at work. Facilitators included shorter meditation practices and the availability of multiple formats and types of intervention content.

Conclusions

The findings of this study suggest that efforts to improve intervention engagement should focus on organizational-level factors rather than individual participant characteristics. Future research should explore the effect of mindfulness practice on the efficiency and effectiveness of 9-1-1 telecommunicators at work.

Trial Registration

ClinicalTrials.gov NCT02961621; https://clinicaltrials.gov/ct2/show/NCT02961621

Destress 9-1-1-an online mindfulness-based intervention in reducing stress among emergency medical dispatchers: a randomised controlled trial

OBJECTIVES

Emergency medical dispatchers (EMDs) experience significant stress in the workplace. Yet, interventions aimed at reducing work-related stress are difficult to implement due to the logistic challenges associated with the relatively unique EMD work environment. This investigation tested the efficacy of a 7-week online mindfulness-based intervention (MBI) tailored to the EMD workforce.

METHODS

Active-duty EMDs from the USA and Canada (n=323) were randomly assigned to an intervention or wait list control condition. Participants completed surveys of stress and mindfulness at baseline, post intervention, and 3 months follow-up. Repeated measures mixed effects models were used to assess changes in stress and mindfulness.

RESULTS

Differences between the intervention group and control group in pre-post changes in stress using the Calgary Symptoms of Stress Inventory were statistically significant, with a difference of -10.0 (95% CI: -14.9, -5.2, p<0.001) for change from baseline to post intervention, and a difference of -6.5 (95% CI: -11.9, -1.1, p=0.02) for change from baseline to 3 months follow-up. Change in mindfulness scores did not differ between groups. However, increases in mindfulness scores were correlated with greater reductions in stress for all participants, regardless of group (r=-0.53, p<0.001).

CONCLUSIONS

Development of tailored online MBIs for employees working in challenging work environments offer a promising direction for prevention and intervention. This study found that a short, weekly online MBI for EMDs resulted in reductions in reports of stress. Implications of online MBIs in other emergency responding populations and directions for future research are discussed.

Randomized trial of a web-based survivor intervention on melanoma prevention behaviors of first-degree relatives

OBJECTIVES

Melanoma can be prevented through reducing sun exposure and detected early by increasing examination of skin for lesions. First-degree relatives of melanoma cases have higher risk than the general population and, therefore, could be targets of behavioral interventions through families. We tested the effects of a family-based web delivered intervention to melanoma families on the melanoma risk reduction behaviors of first-degree relatives of melanoma cases.

METHODS

A total of 313 families that included one first-degree relative were recruited to join this randomized trial. All intervention families received access to the Suntalk website developed to promote family communication and behavioral risk reduction among families of melanoma survivors.

RESULTS

First degree relatives in the intervention arm significantly increased their yearly performance of both skin self examination and thorough provider examination from baseline to 12-month follow-up while the control FDRs decreased their yearly performance of both of those behaviors (p's = 0.006 and 0.005, respectively). Several sun protection behaviors increased significantly in FDRs in the intervention arm but not the control arm, including wearing a covering on the head (p = 0.005), staying in available shade (p = 0.008), and avoiding sun exposure during peak hours (p = 0.010). Some of these changes were mediated by perceptions of risk and other process variables.

CONCLUSIONS

A web-based intervention can reduce risk of melanoma through changes in relevant behaviors among first-degree relatives of melanoma survivors. Future research should identify methods for making this type of intervention accessible to more families and for broadening the reach to other types of cancer families.

PRACTICE IMPLICATIONS

This program can be provided to melanoma families to improve their sun protection and screening behaviors, at the point of diagnosis.

Evaluating the Usefulness of Translation Technologies for Emergency Response Communication: A Scenario-Based Study

Background

In the United States, language barriers pose challenges to communication in emergency response and impact emergency care delivery and quality for individuals who are limited English proficient (LEP). There is a growing interest among Emergency Medical Services (EMS) personnel in using automated translation tools to improve communications with LEP individuals in the field. However, little is known about whether automated translation software can be used successfully in EMS settings to improve communication with LEP individuals.

Objective

The objective of this work is to use scenario-based methods with EMS providers and nonnative English-speaking users who identified themselves as LEP (henceforth referred to as LEP participants) to evaluate the potential of two automated translation technologies in improving emergency communication.

Methods

We developed mock emergency scenarios and enacted them in simulation sessions with EMS personnel and Spanish-speaking and Chinese-speaking (Mandarin) LEP participants using two automated language translation tools: an EMS domain-specific fixed-sentence translation tool (QuickSpeak) and a statistical machine translation tool (Google Translate). At the end of the sessions, we gathered feedback from both groups through a postsession questionnaire. EMS participants also completed the System Usability Scale (SUS).

Results

We conducted a total of 5 group sessions (3 Chinese and 2 Spanish) with 12 Chinese-speaking LEP participants, 14 Spanish-speaking LEP participants, and 17 EMS personnel. Overall, communications between EMS and LEP participants remained limited, even with the use of the two translation tools. QuickSpeak had higher mean SUS scores than Google Translate (65.3 vs 48.4; P=.04). Although both tools were deemed less than satisfactory, LEP participants showed preference toward the domain-specific system with fixed questions (QuickSpeak) over the free-text translation tool (Google Translate) in terms of understanding the EMS personnel’s questions (Chinese 11/12, 92% vs 3/12, 25%; Spanish 12/14, 86% vs 4/14, 29%). While both EMS and LEP participants appreciated the flexibility of the free-text tool, multiple translation errors and difficulty responding to questions limited its usefulness.

Conclusions

Technologies are emerging that have the potential to assist with language translation in emergency response; however, improvements in accuracy and usability are needed before these technologies can be used safely in the field.

Building Back Better: Local Health Department Engagement and Integration of Health Promotion into Hurricane Harvey Recovery Planning and Implementation

Disaster recovery provides an opportunity to build healthier and more resilient communities. However, opportunities and challenges encountered by local health departments (LHDs) when integrating health considerations into recovery have yet to be explored. Following Hurricane Harvey, 17 local health and emergency management officials from 10 agencies in impacted Texas, USA jurisdictions were interviewed to describe the types and level of LHD engagement in disaster recovery planning and implementation and the extent to which communities leveraged recovery to build healthier, more resilient communities. Interviews were conducted between December 2017 and January 2018 and focused on if and how their communities were incorporating public health considerations into the visioning, planning, implementation, and assessment phases of disaster recovery. Using a combined inductive and deductive approach, we thematically analyzed interview notes and/or transcripts. LHDs reported varied levels of engagement and participation in activities to support their community’s recovery. However, we found that LHDs rarely articulated or informed decision makers about the health impacts of recovery activities undertaken by other sectors. LHDs would benefit from additional resources, support, and technical assistance designed to facilitate working across sectors and building resilience during recovery.

All in the family? Communication of cancer survivors with their families

Families often bear the burden of communication about cancer risk, as well as support during and after treatment for cancer in family members. These activities are left up to survivors and their families, with little support or knowledge of useful methods. We present data on aspects of family that are most relevant to risk of cancer-related communication and health promotion among family members. Families (a survivor, one first-degree relative and one parent; n = 313 families) were enrolled in the survey-based study. We assessed multiple aspects of family communication about risk for melanoma among family participants. Families communicate less frequently than desired about cancer risk. Most families do identify a "family health provider" who keeps family data and serves a resource for family members. The reasons given for lack of family communication are diverse but many can be addressed as part of a family communication intervention. Families are poised to improve their family communication about cancer risk and so can play a role in increasing the health of their members.

Impact of new technologies on stress, attrition and well-being in emergency call centers: the NextGeneration 9-1-1 study protocol

BACKGROUND

Our public health emergency response system relies on the "first of the first responders"-the emergency call center workforce that handles the emergency needs of a public in distress. Call centers across the United States have been preparing for the "Next Generation 9-1-1" initiative, which will allow citizens to place 9-1-1 calls using a variety of digital technologies. The impacts of this initiative on a workforce that is already highly stressed is unknown. There is concern that these technology changes will increase stress, reduce job performance, contribute to maladaptive coping strategies, lower employee retention, or change morale in the workplace. Understanding these impacts to inform approaches for mitigating the health and performance risks associated with new technologies is crucial for ensuring the 911 system fulfills its mission of providing optimal emergency response to the public.

METHODS

Our project is an observational, prospective cohort study framed by the first new technology that will be implemented: text-to-911 calling. Emergency center call takers will be recruited nationwide. Data will be collected by online surveys distributed at each center before text-to-911 implementation; within the first month of implementation; and 6 months after implementation. Primary outcome measures are stress as measured by the Calgary Symptoms of Stress Index, use of sick leave, job performance, and job satisfaction. Primary analyses will use mixed effects regression models and mixed effects logistic regression models to estimate the change in outcome variables associated with text-to-911 implementation. Multiple secondary analyses will examine effects of stress on absenteeism; associations between technology attitudes and stress; effects of implementation on attitudes towards technology; and mitigating effects of job demands, job satisfaction, attitudes towards workplace technology and workplace support on change in stress.

DISCUSSION

Our public health dependence on this workforce for our security and safety makes it imperative that the impact of technological changes such as text-to-911 are researched so appropriate intervention efforts to can be developed. Failing to protect our 9-1-1 call takers from predictable health risks would be similar to knowingly exposing field emergency responders to a toxic situation without following OSHA required training and practice standards assuring their protection.

Protocol: a multi-level intervention program to reduce stress in 9-1-1 telecommunicators

BACKGROUND

Nationwide, emergency response systems depend on 9-1-1 telecommunicators to prioritize, triage, and dispatch assistance to those in distress. 9-1-1 call center telecommunicators (TCs) are challenged by acute and chronic workplace stressors: tense interactions with citizen callers in crisis; overtime; shift-work; ever-changing technologies; and negative work culture, including co-worker conflict. This workforce is also subject to routine exposures to secondary traumatization while handling calls involving emergency situations and while making time urgent, high stake decisions over the phone. Our study aims to test the effectiveness of a multi-part intervention to reduce stress in 9-1-1 TCs through an online mindfulness training and a toolkit containing workplace stressor reduction resources.

METHODS/DESIGN

The study employs a randomized controlled trial design with three data collection points. The multi-part intervention includes an individual-level online mindfulness training and a call center-level organizational stress reduction toolkit. 160 TCs will be recruited from 9-1-1 call centers, complete a baseline survey at enrollment, and are randomly assigned to an intervention or a control group. Intervention group participants will start a 7-week online mindfulness training developed in-house and tailored to 9-1-1 TCs and their call center environment; control participants will be "waitlisted" and start the training after the study period ends. Following the intervention group's completion of the mindfulness training, all participants complete a second survey. Next, the online toolkit with call-center wide stress reduction resources is made available to managers of all participating call centers. After 3 months, a third survey will be completed by all participants. The primary outcome is 9-1-1 TCs' self-reported symptoms of stress at three time points as measured by the C-SOSI (Calgary Symptoms of Stress Inventory). Secondary outcomes will include: perceptions of social work environment (measured by metrics of social support and network conflict); mindfulness; and perceptions of social work environment and mindfulness as mediators of stress reduction.

DISCUSSION

This study will evaluate the effectiveness of an online mindfulness training and call center-wide stress reduction toolkit in reducing self-reported stress in 9-1-1 TCs. The results of this study will add to the growing body of research on worksite stress reduction programs.

TRIAL REGISTRATION

ClinicalTrials.gov Registration Number: NCT02961621 Registered on November 7, 2016 (retrospectively registered).

Simulation training to improve 9-1-1 dispatcher identification of cardiac arrest: A randomized controlled trial

BACKGROUND

The objective of this study was to test the effectiveness of simulation training, using actors to make mock calls, on improving Emergency Medical Dispatchers' (EMDs) ability to recognize the need for, and reduce the time to, telephone-assisted CPR (T-CPR) in simulated and real cardiac arrest 9-1-1 calls.

METHODS

We conducted a parallel prospective randomized controlled trial with n=157 EMDs from thirteen 9-1-1 call centers. Study participants were randomized within each center to intervention (i.e., completing 4 simulation training sessions over 12-months) or control (status quo). After the intervention period, performance on 9 call processing skills and 2 time-intervals were measured in 2 simulation assessment calls for both arms. Six of the 13 call centers provided recordings of real cardiac arrest calls taken by study participants during the study period.

RESULTS

Of the N=128 EMDs who completed the simulation assessment, intervention participants (n=66) performed significantly better on 6 of 9 call processing skills and started T-CPR 23s faster (73 vs 91s respectively, p<0.001) compared to participants in the control arm (n=62). In real cardiac arrest calls, EMDs who completed 3 or 4 training sessions were more likely to recognize the need for T-CPR for more challenging cardiac arrest calls than EMDs who completed fewer than 3, including controls who completed no training (68% vs 53%, p=0.018).

CONCLUSIONS

Simulation training improves call processing skills and reduces time to T-CPR in simulated call scenarios, and may improve the recognition of the need for T-CPR in more challenging real-life cardiac arrest calls.

CLINICAL TRIAL REGISTRATION

http://www.clinicaltrials.gov Trial # NCT01972087.

Effects of a web-based intervention on women's breast health behaviors

Helping women make choices to reduce cancer risk and to improve breast health behaviors is important, but the best ways to reach more people with intervention assistance is not known. To test the efficacy of a web-based intervention designed to help women make better breast health choices, we adapted our previously tested, successful breast health intervention package to be delivered on the Internet, and then we tested it in a randomized trial. We recruited women from the general public to be randomized to either an active intervention group or a delayed intervention control group. The intervention consisted of a specialized website providing tailored and personalized risk information to all participants, followed by offers of additional support if needed. Follow-up at one-year post randomization revealed significant improvements in mammography screening in intervention women compared with control women (improvement of 13 percentage points). The intervention effects were more powerful in women who increased breast health knowledge and decreased cancer worry during intervention. These data indicate that increases in mammography can be accomplished in population-based mostly insured samples by implementing this simple, low resource intensive intervention.

Communication Among Melanoma Family Members

Interventions to improve communication among family members may facilitate information flow about familial risk and preventive health behaviors. This is a secondary analysis of the effects of an interactive website intervention aimed at increasing communication frequency and agreement about health risk among melanoma families. Participants were family units, consisting of one family member with melanoma identified from a previous research study (the Case) and an additional first degree relative and a parent of a child 0-17. Family triads were randomized to receive access to the website intervention or to serve as control families. Family communication frequency and agreement about melanoma prevention behaviors and beliefs were measured at baseline and again at 1 year post randomization. Intervention participants of all three types significantly increased the frequency of communication to their first degree relatives (Parents, siblings, children; range = 14-18 percentage points; all p < .05). At baseline, approximately two-thirds of all three family members talked with at least some member of the family about cancer risk. Agreement between Cases and First Degree Relatives and between Cases and Parents increased from pre to post intervention in the intervention participants compared to the control participants (p < .05). These findings provide support for interventions to improve family communication about cancer risk.

Delivering 9-1-1 CPR Instructions to Limited English Proficient Callers: A Simulation Experiment

Having 911 telecommunicators deliver CPR instructions increases cardiac arrest survival, but limited English proficiency (LEP) decreases the likelihood callers will perform CPR and increases time to first compression. The objective of our study was to assess which 9-1-1 CPR delivery modes could decrease time to first compression and improve CPR quality for LEP callers. 139 LEP Spanish and Chinese speakers were randomized into three arms: receiving CPR instructions from a 9-1-1 telecommunicator (1) with telephone interpretation, (2) using alternative, simple ways to rephrase, or (3) who strictly adhered to protocol language. Time interval from call onset to first compression, and CPR quality were the main outcomes. The CPR quality was poor across study arms. Connecting to interpreter services added almost 2 min to the time. CPR training in LEP communities, and regular CPR training for phone interpreters may be necessary to improve LEP bystander CPR quality.

Coordinating Care for Falls via Emergency Responders: A Feasibility Study of a Brief At-Scene Intervention

Falls account for a substantial portion of 9-1-1 calls, but few studies have examined the potential for an emergency medical system role in fall prevention. We tested the feasibility and effectiveness of an emergency medical technician (EMT)-delivered, at-scene intervention to link elders calling 9-1-1 for a fall with a multifactorial fall prevention program in their community. The intervention was conducted in a single fire department in King County, Washington and consisted of a brief public health message about the preventability of falls and written fall prevention program information left at scene. Data sources included 9-1-1 reports, telephone interviews with intervention department fallers and sociodemographically comparable fallers from three other fire departments in the same county, and in-person discussions with intervention department EMTs. Interviews elicited faller recall and perceptions of the intervention, EMT perceptions of intervention feasibility, and resultant referrals. Sixteen percent of all 9-1-1 calls during the intervention period were for falls. The intervention was delivered to 49% of fallers, the majority of whom (75%) were left at scene. Their mean age (N = 92) was 80 ± 8 years; 78% were women, 39% had annual incomes under $20K, and 34% lived alone. Thirty-five percent reported that an EMT had discussed falls and fall prevention (vs. 8% of comparison group, P < 0.01); 84% reported that the information was useful. Six percent reported having made an appointment with a fall prevention program (vs. 3% of comparison group). EMTs reported that the intervention was worthwhile and did not add substantially to their workload. A brief, at-scene intervention is feasible and acceptable to fallers and EMTs. Although it activates only a small percent to seek out fall prevention programs, the public health impact of this low-cost strategy may be substantial.

Evaluation of a Public Education Program Delivered by Firefighters on Early Recognition of a Heart Attack

The Heart Attack Survival Kit (HASK) project is a prospective, randomized trial, testing the effectiveness of an intervention delivered door-to-door by firefighters to increase use of 911 and ingestion of aspirin for symptoms of acute myocardial infarction (AMI) among seniors in King County, Washington. Firefighters visited 24,582seniors in King County, Washington and delivered a Heart Attack Survival Kit. Another 24,191 senior households served as the control group. Outcomes of the program were measured by tracking 911 calls as well as survey data. This study reports on the results of the telephone survey with a random sample of seniors (N = 323) to assess their knowledge of and intentions to act during a heart emergency. Results of a logistic regression analysis showed that being female, be ing younger, and remembering the kit was significantly related to intentions to act appropriately to AMI symptoms. The results are discussed in terms of public education around AMI.

Protocol: simulation training to improve 9-1-1 dispatcher identification of cardiac arrest

Background

9-1-1 dispatchers are often the first contact for bystanders witnessing an out-of-hospital cardiac arrest. In the time before Emergency Medical Services arrives, dispatcher identification of the need for, and provision of Telephone-CPR (T-CPR) can improve survival. Our study aims to evaluate the use of phone-based standardized patient simulation training to improve identification of the need for T-CPR and shorten time to start of T-CPR instructions.

Methods/Design

The STAT-911 study is a randomized controlled trial. We will recruit 160 dispatchers from 9-1-1 call-centers in the Pacific Northwest; they are randomized to an intervention or control group. Intervention participants complete four telephone simulation training sessions over 6–8 months. Training sessions consist of three mock 9-1-1 calls, with a standardized patient playing a caller witnessing a medical emergency. After the mock calls, an instructor who has been listening in and scoring the dispatcher’s call management, connects to the dispatcher and provides feedback on select call processing skills. After the last training session, all participants complete the simulation test: a call session that includes two mock 9-1-1 calls of medium complexity. During the study, audio from all actual cardiac arrest calls handled by the dispatchers will be collected. All dispatchers complete a baseline survey, and after the intervention, a follow-up survey to measure confidence. Primary outcomes are proportion of calls where dispatchers identify the need for T-CPR, and time to start of T-CPR, assessed by comparing performance on two calls in the simulation test. Secondary outcomes are proportion of actual cardiac arrest calls in which dispatchers identify the need for T-CPR and time to start of T-CPR; performance on call-taking skills during the simulation test; self-reported confidence in the baseline and follow-up surveys; and calculated costs of the intervention training sessions and projected costs for field implementation of training sessions.

Discussion

The STAT-911 study will evaluate if over-the-phone simulation training with standardized patients can improve 9-1-1 dispatchers’ ability identify the need for, and promptly begin T-CPR. Furthermore, it will advance knowledge on the effectiveness of simulation training for health services phone-operators interacting with clients, patients, or bystanders in diagnosis, triage, and treatment decisions.

Trial registration

ClinicalTrials.gov Registration Number: NCT01972087. Registered 23 October 2013.

Medical interpreters and bilingual school staff: Potential disaster information conduits?

OBJECTIVES

Dissemination of trusted disaster information to limited English proficient (LEP) communities may mitigate the negative effects these higher risk communities experience in disasters. For immigrant communities, disaster messages may be perceived with skepticism, and fear of public officials may affect compliance with disaster messages. This study explores whether medical interpreters (MIs) and bilingual school staff (BSS) are already informal information sources for LEP communities, and could their connection to both public service organizations and LEP communities make them ideal efficient, trusted disaster information conduits for LEP communities.

DESIGN

The authors conducted a mixed methods study, which included MI individual interviews, Latino community focus groups, an MI employer survey, and school administrator interviews.

SETTING

To ensure diversity in the sample, data were collected in both Los Angeles and Seattle.

RESULTS

MIs, MI employers, and schools are willing to communicate disaster information to LEP communities. MIs and BSS are connected to and share information with LEP communities. Latino LEP communities are eager for more disaster information and sources.

CONCLUSIONS

The study adds to the evidence that a multipronged approach that includes collaborating with professionals linked to immigrant communities, such as MIs and BSS, could be an effective method of disaster information dissemination. Working with MIs and BSS as part of a wider dissemination strategy would promote a community-based interpersonal flow of information that would contribute to LEP community's trust in the message.

Effects of web-based intervention on risk reduction behaviors in melanoma survivors

PURPOSE

Melanoma is the most severe form of skin cancer, and survivors of melanoma carry increased risk of additional melanoma diagnosis. Multiple methods exist for primary and secondary prevention of melanoma in survivors. This study tested a web-based family communication intervention to improve these preventive behaviors in melanoma families.

METHODS

Families (a survivor, at least one first-degree relative and a parent) were randomized either to receive the intervention package or to serve as comparison families. We assessed melanoma prevention behaviors in each cohort member before and after the intervention. The intervention was a web-based multicomponent intervention focused on increasing family communication and exchange of risk information.

RESULTS

Results indicated that, compared to comparison survivors, intervention survivors improved their skin self-examination and their sun protection behaviors significantly from before to after intervention.

CONCLUSION

These data support the use of web-based interventions for behavioral changes in survivors and allow for consideration of dissemination of this successful intervention. These data have implications for interventions that can help cancer families deal with issues of risk and illness.

IMPLICATIONS FOR CANCER SURVIVORS

These data indicate that survivors can benefit from exposure to a website that helps direct their future health behaviors.

Impact of English proficiency on care experiences in a pediatric emergency department

OBJECTIVE

To compare emergency department care experiences of Spanish-speaking, limited-English-proficient (SSLEP) and English-proficient (EP) parents and to assess how SSLEP care experiences vary by parent-perceived interpretation accuracy.

METHODS

The National Research Corporation Picker Institute's Family Experience Survey (FES) was administered from November 26, 2010, to July 17, 2011, to 478 EP and 152 SSLEP parents. Problem scores for 3 FES dimensions were calculated: information/education, partnership with clinicians, and access/coordination of care. Adjusted associations between language proficiency (SSLEP vs EP) and dimension problem scores were examined by multivariate Poisson regression. Unadjusted Poisson regression analysis was used to examine the association between perceived interpretation accuracy and FES problem scores for SSLEP parents who received interpretation.

RESULTS

SSLEP parents had a higher risk of reporting problems with access/coordination of care compared to EP parents (risk ratio 1.6, 95% confidence interval 1.2, 2.1). There were no differences in reported care experiences related to information/education or partnership with clinicians. Among SSLEP parents who received professional interpretation, those reporting poor accuracy had a higher risk of also reporting problems with information/education (risk ratio 2.1, 95% confidence interval 1.2, 3.6).

CONCLUSIONS

In a pediatric emergency department with around-the-clock access to professional interpretation, SSLEP parents report poorer experiences than EP parents with access/coordination of care, including perceived wait times. Their experiences with provision of information/education and partnership with clinicians approximate those of EP parents. However, SSLEP parents who perceive poor interpretation accuracy report more problems understanding information provided about their child's illness and care.

Changes to DA-CPR instructions: can we reduce time to first compression and improve quality of bystander CPR?

INTRODUCTION

Dispatcher-assisted CPR (DA-CPR) can increase rates of bystander CPR, survival, and quality of life following cardiac arrest. Dispatcher protocols designed to improve rapid recognition of arrest and coach CPR may increase survival by (1) reducing preventable time delays to start of chest compressions and (2) improving the quality of bystander CPR.

METHODS

We conducted a randomized controlled trial comparing a simplified DA CPR script to a conventional DA CPR script in a manikin cardiac arrest simulation with lay participants. The primary outcomes measured were the time interval from call receipt to the first chest compression and the core metrics of chest compression (depth, rate, release, and compression fraction). CPR was measured using a recording manikin for the first 3 min of participant CPR.

RESULTS

Of the 75 participants, 39 were randomized to the simplified instructions and 36 were randomized to the conventional instructions. The interval from call receipt to first compression was 99 s using the simplified script and 124 s using the conventional script for a difference of 24s (p<0.01). Although hand position was judged to be correct more often in the conventional instruction group (88% versus 63%, p<0.01), compression depth was an average 7 mm deeper among those receiving the simplified CPR script (32 mm versus 25 mm, p<0.05). No statistically significant differences were detected between the two instruction groups for compression rate, complete release, number of hands-off periods, or compression fraction.

DISCUSSION

Simplified DA-CPR instructions to lay callers in simulated cardiac arrest settings resulted in significant reductions in time to first compression and improvements in compression depth. These results suggest an important opportunity to improve DA CPR instructions to reduce delays and improve CPR quality.

Understanding older adults' motivators and barriers to participating in organized programs supporting exercise behaviors

Little is known about older adults' perceptions of organized programs that support exercise behavior. We conducted semi-structured interviews with 39 older adults residing in King County, Washington, who either declined to join, joined and participated, or joined and then quit a physical activity-oriented program. We sought to explore motivators and barriers to physical activity program participation and to elicit suggestions for marketing strategies to optimize participation. Two programs supporting exercise behavior and targeting older persons were the source of study participants: Enhance(®)Fitness and Physical Activity for a Lifetime of Success. We analyzed interview data using standard qualitative methods. We examined variations in themes by category of program participant (joiner, decliner, quitter) as well as by program and by race. Interview participants were mostly females in their early 70s. Approximately half were non-White, and about half had graduated from college. The most frequently cited personal factors motivating program participation were enjoying being with others while exercising and desiring a routine that promoted accountability. The most frequent environmental motivators were marketing materials, encouragement from a trusted person, lack of program fees, and the location of the program. The most common barriers to participation were already getting enough exercise, not being motivated or ready, and having poor health. Marketing messages focused on both personal benefits (feeling better, social opportunity, enjoyability) and desirable program features (tailored to individual needs), and marketing mechanisms ranged from traditional written materials to highly personalized approaches. These results suggest that organized programs tend to appeal to those who are more socially inclined and seek accountability. Certain program features also influence participation. Thoughtful marketing that involves a variety of messages and mechanisms is essential to successful program recruitment and continued attendance.

Factors associated with the adoption of a patient education intervention among first responders, King County, Washington, 2010-2011

Introduction

This study investigated facilitators and barriers to adoption of an at-scene patient education program by firefighter emergency medical technicians (EMTs) in King County, Washington.

Methods

We consulted providers of emergency medical services (EMS) to develop a patient education pamphlet in the form of a tear-off sheet that could be attached to the EMT medical incident report. The pamphlet included resources for at-scene patient education on high blood pressure, blood glucose, falls, and social services. The program was launched in 29 fire departments in King County, Washington, on January 1, 2010, and a formal evaluation was conducted in late 2011. We developed a survey based on diffusion theory to assess 1) awareness of the pamphlet, 2) evaluation of the pamphlet attributes, 3) encouragement by peers and superiors for handing out the pamphlet, 4) perceived behavioral norms, and 5) demographic variables associated with self-reported adoption of the at-scene patient education program. The survey was completed by 822 (40.1%) of 2,047 firefighter emergency medical technicians. We conducted bivariate and multivariable analyses to assess associations between independent variables and self-reported adoption of the program.

Results

Adoption of the at-scene patient education intervention was significantly associated with positive evaluation of the pamphlet, encouragement from peers and superiors, and perceived behavioral norms. EMS providers reported they were most likely to hand out the pamphlet to patients in private residences who were treated and left at the scene.

Conclusion

Attributes of chronic disease prevention programs and encouragement from peers and supervisors are necessary in diffusion of patient education interventions in the prehospital care setting.

Hypertension identification via emergency responders: a randomized controlled intervention study

OBJECTIVE

The objective was to test the effectiveness of a mail campaign that included blood pressure (BP) measurements from patients treated by emergency medical technicians (EMTs) to motivate them to (re)check their BP at a fire station. The mailing used a 2×2 research design tailoring on risk and source personalization.

METHOD

In this randomized controlled trial, participants were randomized into a control group or one of four experimental groups. Participants residing in one of four fire departments in a Pacific Northwest metropolitan area were eligible if they had a systolic BP≥160 mm Hg and/or diastolic BP≥100 mm Hg when seen by EMTs during the study period (July 2007-September 2009).

RESULTS

Of 7106 eligible participants, 40.7% were reached for a follow-up interview. Multivariable logistic regression analysis showed that although the absolute number of fire station BP checks was low (4%), participants who received any mailed intervention had a 3 to 5-fold increase in the odds of reporting a fire station BP check over controls. Fire station visits did not differ by type of tailored mailing.

CONCLUSION

Partnering with Emergency Medical Services is an innovative way to identify high-risk community members for population health interventions.

Early Experience with a Web-based Intervention to Inform Risk of Breast Cancer

The Internet might transform the way in which health information is communicated to patient and general populations. Understanding differences in usage patterns will be critically important to ensuring the successful distribution of health information. The present study presents early data on the use patterns and predictors of use of a Web-based intervention in a population-based subsample of women aged 18-74 in King County, WA. By three months over half (51%) of users had logged into the website, using multiple components. Predictors of use by three months included employment, perceptions of health and mental health scores. These data have implications for how to conduct Web-based intervention research and for individuals that may not benefit from such interventions.

Improving low-wage, midsized employers' health promotion practices: a randomized controlled trial

BACKGROUND

The Guide to Community Preventive Services (Community Guide) offers evidence-based intervention strategies to prevent chronic disease. The American Cancer Society (ACS) and the University of Washington Health Promotion Research Center co-developed ACS Workplace Solutions (WPS) to improve workplaces' implementation of Community Guide strategies.

PURPOSE

To test the effectiveness of WPS for midsized employers in low-wage industries.

DESIGN

Two-arm RCT; workplaces were randomized to receive WPS during the study (intervention group) or at the end of the study (delayed control group).

SETTING/PARTICIPANTS

Forty-eight midsized employers (100-999 workers) in King County WA.

INTERVENTION

WPS provides employers one-on-one consulting with an ACS interventionist via three meetings at the workplace. The interventionist recommends best practices to adopt based on the workplace's current practices, provides implementation toolkits for the best practices the employer chooses to adopt, conducts a follow-up visit at 6 months, and provides technical assistance.

MAIN OUTCOME MEASURES

Employers' implementation of 16 best practices (in the categories of insurance benefits, health-related policies, programs, tracking, and health communications) at baseline (June 2007-June 2008) and 15-month follow-up (October 2008-December 2009). Data were analyzed in 2010-2011.

RESULTS

Intervention employers demonstrated greater improvement from baseline than control employers in two of the five best-practice categories; implementing policies (baseline scores: 39% program, 43% control; follow-up scores: 49% program, 45% control; p=0.013) and communications (baseline scores: 42% program, 44% control; follow-up scores: 76% program, 55% control; p=0.007). Total best-practice implementation improvement did not differ between study groups (baseline scores: 32% intervention, 37% control; follow-up scores: 39% intervention, 42% control; p=0.328).

CONCLUSIONS

WPS improved employers' health-related policies and communications but did not improve insurance benefits design, programs, or tracking. Many employers were unable to modify insurance benefits and reported that the time and costs of implementing best practices were major barriers.

TRIAL REGISTRATION

This study is registered at clinicaltrials.gov NCT00452816.

Complications after acute coronary syndrome are reduced by perceived control of cardiac illness

AIMS

To investigate the relationship between anxiety, perceived control and rate of in-hospital complications after acute coronary syndrome.

BACKGROUND

Anxiety may be associated with higher risk of complications following acute myocardial infarction; perceived control may moderate this relationship.

DESIGN

Prospective observational study.

METHODS

Patients enrolled in a trial investigating delay in seeking treatment for acute coronary syndrome had anxiety measured at enrolment and 3 months using the Brief Symptom Inventory anxiety subscale. The acute coronary syndrome hospital presentations investigated occurred between 2001-2006. Patients with anxiety scores greater than the population norm at both time points were categorized as persistently anxious. Perceived control was measured at enrolment using the control attitudes scale-revised. Data were collected from the medical record on in-hospital complications in patients presenting with acute coronary syndrome within 2 years of enrolment. Chi-square and t-tests were used for univariate analyses and multiple logistic regression to identify independent predictors of complications.

RESULTS

Patients (n = 171) were 64% men with mean age 69 years. Ischaemic or arrhythmic complications occurred in 26 patients (15%) with no difference in complication rates between those persistently anxious and others. Important univariate predictors of in-hospital complications were lower perceived control, diagnosis of acute myocardial infarction, heart failure and higher pulse rate on admission. Low perceived control and diagnosis of acute myocardial infarction were independent predictors of in-hospital complications in the multiple logistic regression.

CONCLUSION

Perceived control, but not persistent anxiety, prior to acute coronary syndrome was an important predictor of in-hospital complications after acute coronary syndrome. Interventions to increase cardiac patients' perceived control of their cardiac illness may reduce in-hospital complications after acute coronary syndrome.

Who listens to our advice? A secondary analysis of data from a clinical trial testing an intervention designed to decrease delay in seeking treatment for acute coronary syndrome

OBJECTIVE

Prolonged prehospital delay in persons experiencing acute coronary syndrome (ACS) remains a problem. Understanding which patients respond best to particular interventions designed to decrease delay time would provide mechanistic insights into the process by which interventions work.

METHODS

In the PROMOTION trial, 3522 at-risk patients were enrolled from 5 sites in the United States (56.4%), Australia and New Zealand; 490 (N=272 intervention, N=218 control) had an acute event within 2 years. Focusing on these 490, we (1) identified predictors of a rapid response to symptoms, (2) identified intervention group subjects with a change in these predictors over 3 months of follow-up, and (3) compared intervention group participants with and without the favorable response pattern. Hypothesized predictors of rapid response were increased perceived control and decreased anxiety. Knowledge, attitudes, and beliefs were hypothesized to differ between responders and non-responders.

RESULTS

Contrary to hypothesis, responders had low anxiety and low perceived control. Only 73 (26.8%) subjects showed this pattern 3 months following the intervention. No differences in ACS knowledge, attitudes, or beliefs were found.

CONCLUSION

The results of this study challenge existing beliefs.

PRACTICE IMPLICATIONS

New intervention approaches that focus on a realistic decrease in anxiety and perceived control are needed.

Predictors of recruited melanoma families into a behavioral intervention project

BACKGROUND

Examination of families represents an important priority in health research. In this paper we report on individual and family-level factors associated with enrollment in a cancer prevention research project. We approached families affected by melanoma for possible participation in a randomized controlled trial of a web-based communication and support intervention.

METHODS

We recruited three family members per family for assessment - the melanoma case, a first-degree relative (FDR), and a relative who is a parent of a child age 18 or younger. Recruitment involved three steps: requesting the physician's consent to approach the melanoma case, approaching the case to request their participation and family contact information, and they approaching the FDRs and parents.

RESULTS

Of the 1380 families approached, 313 were enrolled, 263 were excluded because we could not find or contact a family member (FDR or parent), 331 did not have eligible family members, and 473 refused. The most frequently noted reason for refusal was being too busy or having no time. The primary predictors of participation for cases (OR=1.6; CI=1.01-2.51) and FDRs (OR=2.15; CI=1.11-4.13) included higher educational attainment. FDRs were more likely to enroll if they were female (OR=1.77; CI=1.1-.85) and parents were more likely to enroll if the case had been diagnosed more recently (OR=3.3; CI=1.9-5.93), if the parent was partnered (OR=4.37; CI=1.86-10.26), and if the parent lived in the same city as the case (OR=2.88; CI=1.08-7.68).

CONCLUSIONS

The results can provide information on potential directions for future family recruitment.

Engagement in "My Child's Asthma", an interactive web-based pediatric asthma management intervention

PURPOSE

The Internet is a promising tool for delivering health behavior change programs although such interventions raise questions about participant engagement in this medium. In this study we sought to determine the characteristics of parents who engage in an Internet-based health intervention for their children (with asthma) and to distinguish parents who engage at the prescribed intervals versus those who engage less often.

METHODS

N=283 parents with children who had asthma were recruited and randomized to receive a web-based intervention. Participants filled out six surveys over a 6-month period asking them about demographic and clinical characteristics, outcome expectations and self-efficacy beliefs regarding asthma control for their child, and attitudes about computers and the Internet. Descriptive statistics were used to describe the population and analyze associations.

RESULTS

Controller use and being adherent to this medication as well as positive outcome and self efficacy expectations were associated with increased engagement. Parents who logged on only once reported significantly less frequent use of the Internet than parents who logged on to all sessions.

DISCUSSION AND CONCLUSION

The results of this study suggest that it is important to find ways to increase engagement in a web-based intervention for parents who are not yet engaging in the recommended behaviors and/or who report less positive outcome and efficacy expectations around asthma management.

Older adults' perceptions of clinical fall prevention programs: a qualitative study

Objective. To investigate motivational factors and barriers to participating in fall risk assessment and management programs among diverse, low-income, community-dwelling older adults who had experienced a fall. Methods. Face-to-face interviews with 20 elderly who had accepted and 19 who had not accepted an invitation to an assessment by one of two fall prevention programs. Interviews covered healthy aging, core values, attributions/consequences of the fall, and barriers/benefits of fall prevention strategies and programs. Results. Joiners and nonjoiners of fall prevention programs were similar in their experience of loss associated with aging, core values they expressed, and emotional response to falling. One difference was that those who participated endorsed that they "needed" the program, while those who did not participate expressed a lack of need. Conclusions. Interventions targeted at a high-risk group need to address individual beliefs as well as structural and social factors (transportation issues, social networks) to enhance participation.

Psychologic effects of automated external defibrillator training: a randomized trial

OBJECTIVE

The objective of this study was to test whether an automated external defibrillator (AED) training program would positively affect the mental health of family members of high-risk patients.

METHODS

A total of 305 patients with ischemic heart disease and their family members were randomized to 1 of 4 AED training programs: 2 video-based training programs and 2 face-to-face training programs that emphasized self-efficacy and perceived control. Patients and family members were surveyed at baseline and 3 and 9 months postischemic event on demographic characteristics, measures of quality of life (Short Form-36), self-efficacy, and perceived control. For this study, family members were the focus rather than the patients.

RESULTS

Regression analyses showed that family members in the face-to-face training programs did not score better on any of the mental health status variables than family members who participated in the other training programs except for an increase in self-efficacy beliefs at 3 months after training.

CONCLUSION

The findings suggest that a specifically designed AED training program emphasizing self-efficacy and perceived control beliefs is not likely to enhance family member mental health.

Effects of a Web-based intervention on women's breast health behaviors

Helping women make choices to reduce cancer risk and to improve breast health behaviors is important, but the best ways to reach more people with intervention assistance is not known. To test the efficacy of a Web-based intervention designed to help women make better breast health choices, we adapted our previously tested, successful breast health intervention package to be delivered on the Internet, and then we tested it in a randomized trial. We recruited women from the general public to be randomized to either an active intervention group or a delayed intervention control group. The intervention consisted of a specialized Web site providing tailored and personalized risk information to all participants, followed by offers of additional support if needed. Follow-up at 1-year post-randomization revealed significant improvements in mammography screening in intervention women compared with control women (improvement of 13 percentage points). The intervention effects were more powerful in women who increased breast health knowledge and decreased cancer worry during intervention. These data indicate that increases in mammography can be accomplished in population-based mostly insured samples by implementing this simple, low resource intensive intervention.

Social marketing, stages of change, and public health smoking interventions

As a "thought experiment," the authors used a modified stages of change model for smoking to define homogeneous segments within various hypothetical populations. The authors then estimated the population effect of public health interventions that targeted the different segments. Under most assumptions, interventions that emphasized primary and secondary prevention, by targeting the Never Smoker, Maintenance, or Action segments, resulted in the highest nonsmoking life expectancy. This result is consistent with both social marketing and public health principles. Although the best thing for an individual smoker is to stop smoking, the greatest public health benefit is achieved by interventions that target nonsmokers.