The role of behavioral science theory in development and implementation of public health interventions.

Increasing evidence suggests that public health and health-promotion interventions that are based on social and behavioral science theories are more effective than those lacking a theoretical base. This article provides an overview of the state of the science of theory use for designing and conducting health-promotion interventions. Influential contemporary perspectives stress the multiple determinants and multiple levels of determinants of health and health behavior. We describe key types of theory and selected often-used theories and their key concepts, including the health belief model, the transtheoretical model, social cognitive theory, and the ecological model. This summary is followed by a review of the evidence about patterns and effects of theory use in health behavior intervention research. Examples of applied theories in three large public health programs illustrate the feasibility, utility, and challenges of using theory-based interventions. This review concludes by identifying cross-cutting themes and important future directions for bridging the divides between theory, practice, and research.

Randomized trial of quality improvement intervention to improve diabetes care in primary care settings.

OBJECTIVE: To assess the impact of a quality improvement (QI) intervention on the quality of diabetes care at primary care clinics. RESEARCH DESIGN AND METHODS: Twelve primary care medical practices were matched by size and location and randomized to intervention or control conditions. Intervention clinic staff were trained in a seven-step QI change process to improve diabetes care. Surveys and medical record reviews of 754 patients, surveys of 329 clinic staff, interviews with clinic leaders, and analysis of training session videotapes evaluated compliance with and impact of the intervention. Mixed-model nested analyses compared differences in the quality of diabetes care before and after intervention. RESULTS: All intervention clinics completed at least six steps of the seven-step QI change process in an 18-month period and, compared with control clinics, had broader staff participation in QI activities (P = 0.04), used patient registries more often (P = 0.03), and had better test rates for HbA(1c) (A1C), LDL, and blood pressure (P = 0.02). Other processes of diabetes care were unchanged. The intervention did not improve A1C (P = 0.54), LDL (P = 0.46), or blood pressure (P = 0.69) levels or a composite of these outcomes (P = 0.35). CONCLUSIONS: This QI change process was successfully implemented but failed to improve A1C, LDL, or blood pressure levels. Data suggest that to be successful, such a QI change process should direct more attention to specific clinical actions, such as drug intensification and patient activation.

A randomized school trial of environmental strategies to encourage fruit and vegetable consumption among children.

The Cafeteria Power Plus project examined whether a cafeteria-based intervention would increase the fruit and vegetable (FV) consumption of children. Twenty-six schools were randomly assigned to either an intervention or control condition. Baseline lunch observations of a sample (N = 1668) of first- and third-grade students occurred in the spring of 2000; follow-up was in the spring of 2002. The intervention took place during two consecutive school years beginning in the fall of 2000 and consisted of daily activities (increasing the availability, attractiveness, and encouragement for FV) and special events (kick-offs, samplings, challenge weeks, theater production, and finale meal). Training of food-service staff and cook managers was ongoing throughout the intervention phase. Students in the intervention schools significantly increased their total fruit intake. Process measures indicated that verbal encouragement by food-service staff was associated with outcomes. The outcomes suggest that multicomponent interventions are more powerful than cafeteria programs alone with this age group.

Variation in diabetes care by age: opportunities for customization of care.

BACKGROUND: The quality of diabetes care provided to older adults has usually been judged to be poor, but few data provide direct comparison to other age groups. In this study, we hypothesized that adults age 65 and over receive lower quality diabetes care than adults age 45-64 years old. METHODS: We conducted a cohort study of members of a health plan cared for by multiple medical groups in Minnesota. Study subjects were a random sample of 1109 adults age 45 and over with an established diagnosis of diabetes using a diabetes identification method with estimated sensitivity 0.91 and positive predictive value 0.94. Survey data (response rate 86.2%) and administrative databases were used to assess diabetes severity, glycemic control, quality of life, microvascular and macrovascular risks and complications, preventive care, utilization, and perceptions of diabetes. RESULTS: Compared to those aged 45-64 years (N = 627), those 65 and older (N = 482) had better glycemic control, better health-related behaviors, and perceived less adverse impacts of diabetes on their quality of life despite longer duration of diabetes and a prevalence of cardiovascular disease twice that of younger patients. Older patients did not ascribe heart disease to their diabetes. Younger adults often had explanatory models of diabetes that interfere with effective and aggressive care, and accessed care less frequently. Overall, only 37% of patients were simultaneously up-to-date on eye exams, foot exams, and glycated hemoglobin (A1c) tests within one year. CONCLUSION: These data demonstrate the need for further improvement in diabetes care for all patients, and suggest that customisation of care based on age and explanatory models of diabetes may be an improvement strategy that merits further evaluation.

Evaluation of a theater production about eating behavior of children.

This study evaluated "All's Well That Eats Well," a theater production performed in 20 schools in the Twin Cities, Minn., metropolitan area in winter 2000. The production sought to change food-related knowledge and food choices concerning fruits and vegetables among children in grades 1-6. The study used a pretest-posttest design with two randomly-assigned, sequential intervention-control groups (N = 4,093). All students completed surveys prior to and then following the theater production and the classroom and home activities. No differences existed between the groups at pretest. Significant differences occurred in food-related knowledge, food choices, and food recall from pretest to posttest for all students. Significant differences also occurred between intervention groups in food-related knowledge and food choices. The study indicates that professional theater productions in schools can create at least a short-term effect on children's nutrition knowledge and behavior.

Contrasting mediating variables in two 5-a-day nutrition intervention programs.

BACKGROUND: Researchers have advocated mediational analysis for behavioral intervention studies to link the supporting theory used in an intervention with the mediating variables and with its ultimate success or failure. Few mediational analyses have been reported for school-based nutrition studies. The conduct of mediational analyses within multi-site studies may provide advantages for the standardization of methods and for the replication and generalizability of findings. METHODS: This study identified mediators of two school-based nutrition interventions for 4th graders. Three variables were tested on the four criteria necessary to establish mediation of intervention effects on changes in fruit and vegetable consumption (FVC) in 4th graders (Alabama, N = 1584; Minnesota, N = 522). FVC was measured in children using 24-h dietary recalls. Mediators were assessed using questionnaires completed by children and parents. RESULTS: All criteria were met in Alabama for a single-item measure of knowledge of the 5-a-day daily consumption guideline. Knowledge and parent consumption satisfied one criterion in Minnesota. Knowledge accounted for 9.78% of the total intervention effect in Alabama. CONCLUSIONS: Knowledge of the 5-a-day guideline for fruit and vegetable consumption may mediate intervention effects. Future work should include tests of mediational models in multi-site studies.

Diabetic patients who smoke: are they different?

BACKGROUND: We wanted to identify differences between diabetic patients who smoke and those who do not smoke to design more effective strategies to improve their diabetes care and encourage smoking cessation. METHODS: A random sample of adult health plan members with diabetes were mailed a survey questionnaire, with telephone follow-up, asking about their attitudes and behaviors regarding diabetes care and smoking. Among the 1,352 respondents (response rate 82.4%), we found 188 current smokers whose answers we compared with those of 1,264 nonsmokers, with statistical adjustment for demographic characteristics and duration of diabetes. RESULTS: Smokers with diabetes were more likely to report fair or poor health (odds ratio [OR] = 1.5, P = .03) and often feeling depressed (OR = 1.7, P = .004). Relative to nonsmokers, smokers had lower rates of checking blood glucose levels, were less physically active, and had fewer diabetes care visits, glycated hemoglobin (A1c) tests, foot examinations, eye examinations, and dental checkups (P < or = .01). Smokers also reported receiving and desiring less support from family and friends for specific diabetic self-management activities and had lower readiness to quit smoking than has been observed in other population groups. CONCLUSIONS: Clinicians should be aware that diabetic patients who smoke are more likely to report often feeling depressed and, even after adjusting for depression, are less likely to be active in self-care or to comply with diabetes care recommendations. Diabetic patients who smoke are special clinical challenges and are likely to require more creative and consistent clinical interventions and support.