Outreach to Low-Income Homebound Older Adults to Increase Access to COVID-19 Self-Test Kits, Missouri, 2022.

COVID-19 self-test kits were distributed to low-income, older adults (n = 2532) with their home-delivered or congregate meals in May 2022. Later, a convenience sample (n = 1108) were contacted for follow-up, and 606 (55%) were reached. Among 79% who remembered getting the test, only 34% already had a test kit, but nearly all liked receiving it (91%) and reported they would use or had used it (93%). Partnering with meal-delivery service providers was feasible to increase access to COVID-19 self-tests for low-income older adults. (Am J Public Health. 2024;114(S1):S65-S68. https://doi.org/10.2105/AJPH.2023.307485).

Addressing COVID-19 Vaccine Hesitancy With Community Distribution of Conversation Cards.

To increase community conversations about COVID-19 vaccine hesitancy, we distributed vaccine cardholders and conversation cards to 6000 newly vaccinated adults at vaccination sites and encouraged them to talk with unvaccinated friends and family members. In 257 onsite exit interviews, we found that cardholders and conversation cards were well liked, and most recipients expected to use them. Follow-up surveys two weeks later showed that 51% of respondents used a card to start a conversation and 41% gave a card to an unvaccinated friend or family member. (Am J Public Health. 2024;114(S1):S87-S91. https://doi.org/10.2105/AJPH.2023.307481).

An Exploratory Qualitative Analysis of Explanations for COVID-19-Related Racial Disparities Among St. Louis Residents: "I Don't Really Pay Attention to the Racial Stuff Very Much".

Introduction: Public health explanations for the disproportionate share of COVID-19-related illness and death among the Black population often differ from lay explanations, which can affect the public's support for policies that address these disparities. This qualitative exploratory study examined the explanatory frameworks for COVID-19-related racial disparities in St. Louis among 54 St. Louis residents. Methods: From August 16, 2021, through May 20, 2022, we conducted semistructured interviews among a convenience sample of 54 St. Louis residents about their experiences during the COVID-19 pandemic. Directed content analysis identified participants' explanatory frameworks for racial disparities in COVID-19-related illness and death. We disaggregated coded excerpts by race, age, education, and income to examine emerging themes. Results: Lay explanatory frameworks for racial disparities in COVID-19 included vaccine mistrust, lack of personal responsibility, low perceived susceptibility to COVID-19, pre-existing conditions or genetic predisposition, institutional racism, barriers to care, low socioeconomic status, insufficient information on COVID-19, and the inability to work remotely. Black interview participants addressed issues of systemic racism, inequitable allocation of COVID-19 vaccines, and institutional mistrust, whereas White participants did not directly acknowledge the role of racism. Both Black and White participants identified lack of personal responsibility among young Black people as a source of these disparities. Conclusion: This work identifies a need for improved health communication about racial disparities in COVID-19-related illness and death. Messaging that highlights racism may be less effective among the White population than the Black population in the US, whereas narratives that include the theme of individual choice may appeal broadly. Further research is needed on the use of communication strategies based on lay individuals' explanatory frameworks for COVID-19-related racial disparities to enhance support for equitable public policy.

Appeal of Tobacco Quitline Services Among Low-Income Smokers.

INTRODUCTION: State tobacco quitlines are delivering cessation assistance through an increasingly diverse range of channels. However, offerings vary from state to state, many smokers are unaware of what is available, and it is not yet clear how much demand exists for different types of assistance. In particular, the demand for online and digital cessation interventions among low-income smokers, who bear a disproportionate burden of tobacco-related disease, is not well understood. METHODS: We examined interest in using 13 tobacco quitline services in a racially diverse sample of 1,605 low-income smokers in 9 states who had called a 2-1-1 helpline and participated in an ongoing intervention trial from June 2020 through September 2022. We classified services as standard (used by ≥90% of state quitlines [eg, calls from a quit coach, nicotine replacement therapy, printed cessation booklets]) or nonstandard (mobile app, personalized web, personalized text, online chat with quit coach). RESULTS: Interest in nonstandard services was high. Half or more of the sample reported being very or somewhat interested in a mobile app (65%), a personalized web program (59%), or chatting online with quit coaches (49%) to help them quit. In multivariable regression analyses, younger smokers were more interested than older smokers in digital and online cessation services, as were women and smokers with greater nicotine dependence. CONCLUSION: On average, participants were very interested in at least 3 different cessation services, suggesting that bundled or combination interventions might be designed to appeal to different groups of low-income smokers. Findings provide some initial hints about potential subgroups and the services they might use in a rapidly changing landscape of behavioral interventions for smoking cessation.

Factors associated with initiation and continuation of endocrine therapy in women with hormone receptor-positive breast cancer.

BACKGROUND: Despite benefits of endocrine therapy (ET) for patients with hormone-receptor (HR)-positive breast cancer, many patients do not initiate or discontinue ET against recommendations. METHODS: We identified variables associated with ET initiation and continuation, analyzing pooled data from two longitudinal studies at a National Cancer Institute comprehensive cancer center in St. Louis, Missouri. The sample included 533 women with newly diagnosed, non-metastatic, HR-positive breast cancer who completed interviews at enrollment and 6, 12, and 24 months after definitive surgical treatment. Logistic regression models estimated the adjusted odds ratio and 95% confidence interval (aOR [95% CI]) for each of self-reported ET initiation by the 12-month interview and continuation for ≥12 months by the 24-month interview in association with self-reported diabetes, elevated depressed mood, menopausal-symptom severity and obesity, adjusting for race, age, insurance status, chemotherapy, and radiation therapy. RESULTS: Overall, 81.4% (434/533) of patients initiated ET, and 86.5% (371/429) continued ET ≥12 months. Patients with diabetes had lower odds of initiating ET (0.50 [0.27-0.91]). Patients reporting greater menopausal-symptom severity had lower odds of continuing ET (0.72 [0.53-0.99]). CONCLUSION: Efforts to increase ET initiation among patients with diabetes and better manage severe menopausal symptoms among ET users might promote ET continuation. CLINICAL TRIAL INFORMATION: ClinicalTrials.gov : #NCT00929084.

Intention to vaccinate children for COVID-19: A segmentation analysis among Medicaid parents in Florida.

COVID-19 vaccines have been granted emergency use authorization for children ages 5 years and older. To understand how racially and ethnically diverse parents of young children enrolled in Medicaid feel about a prospective COVID-19 vaccine for their children, we administered an online survey that included both close-ended and open-ended items to a statewide sample in Florida (n = 1951). We used quantitative responses to conduct a statistical audience segmentation analysis that identified five distinct sub-groups that varied widely in the likelihood that they would get a COVID-19 vaccine for their child. Qualitative responses were used to illustrate differences between the groups. The youngest Black and White mothers were least likely to vaccinate their child (24%), followed by Black and White mothers in their early 30s (36%), younger Hispanic and mixed-race or other race parents (45%), older mothers (48%) and older fathers (71%). Unique challenges to building vaccine confidence emerged for each group. The youngest Black and White mothers were more likely to report their lives being worse during the COVID-19 pandemic, were far more negative and less positive about a COVID-19 vaccine, and were more concerned about paying bills than preventing COVID-19. Younger Hispanic and mixed-race parents were less negative, but more likely to use emotional language (e.g., scared, nervous, worried) talking about a COVID-19 vaccine, and more likely to report that protecting their child's health was their top concern. Recommendations are made for applying the insights gained in outreach and education efforts.

Examining Psychosocial Correlates of a Home Smoking Ban Among Low-income Smokers: Analysis of Social Support, Unmet Social Needs, Perceived Stress, and Depressive Symptoms.

Home smoking bans reduce exposure to second-hand smoke. Understanding how psychosocial factors are related to having a home smoking ban may lead to better interventions for populations less likely to have home smoking bans, including low-income smokers. In this study, we used baseline data from 1,944 participants in a randomized trial of low-income smokers in Missouri to explore psychosocial correlates of a total home smoking ban. Using logistic regression, we examined associations between psychosocial variables (social support, unmet social needs [e.g., food, housing], perceived stress, and depressive symptoms) and a total home smoking ban. 72% of participants were female, and 58% were Black/African American; 26% reported a home smoking ban. In unadjusted and adjusted models, greater social support was associated with greater likelihood of a home smoking ban. Stress was negatively associated with a ban in adjusted models only. The fact that most participants did not have a home smoking ban highlights the need for further intervention in this population. Results suggest links between social support and having a home smoking ban, although effect sizes were small. Smoke-free home interventions that increase social connectedness or leverage existing support may be especially effective. Tobacco control planners may also consider partnering with agencies addressing social isolation.

Addressing Social Needs in Health Care Settings: Evidence, Challenges, and Opportunities for Public Health.

There has been an explosion of interest in addressing social needs in health care settings. Some efforts, such as screening patients for social needs and connecting them to needed social services, are already in widespread practice. These and other major investments from the health care sector hint at the potential for new multisector collaborations to address social determinants of health and individual social needs. This article discusses the rapidly growing body of research describing the links between social needs and health and the impact of social needs interventions on health improvement, utilization, and costs. We also identify gaps in the knowledge base and implementation challenges to be overcome. We conclude that complementary partnerships among the health care, public health, and social services sectors can build on current momentum to strengthen social safety net policies, modernize social services, and reshape resource allocation to address social determinants of health.

Cervical cancer risk and screening among women seeking assistance with basic needs.

BACKGROUND: In the United States, more than half of cervical cancers occur in women who are inadequately screened. Interventions to improve access to cervical cancer preventive care is critical to reduce health inequities. OBJECTIVE: This study aimed to evaluate the need for cervical cancer screening among women seeking assistance with basic needs and to assess best approaches to facilitate Papanicolaou test referral. STUDY DESIGN: This study is a secondary analysis of a randomized controlled trial of low-income female callers to 2-1-1 Missouri, a helpline for local health and social services. The need for cervical cancer screening was assessed. Callers were randomized to 1 of 3 arms, each providing a Papanicolaou test referral: verbal referral only, verbal referral and tailored print reminder, or verbal referral and navigator. The primary outcome was contacting a Papanicolaou test referral 1 month following intervention. Student t tests or Mann-Whitney U tests were used to analyze significant differences in continuous variables, whereas Fisher exact or χ2 tests were used for categorical variables. We stratified by number of unmet basic needs (0-1 vs ≥2) and compared success of contacting a Papanicolaou test referral among study groups (verbal referral vs tailored reminder vs navigator) using the Fisher exact test and χ2 test, respectively. Multivariate logistic regression was used to assess risk factors for nonadherence for Papanicolaou test at baseline and at 1 month follow-up, adjusting for race and ethnicity, age, insurance status, self-rated health, smoking, and study group. RESULTS: Among 932 female callers, 250 (26.8%) needed cervical cancer screening. The frequency of unmet basic needs was high, the most common being lack of money for unexpected expenses (91.2%) and necessities, such as food, shelter, and clothing (73.2%). Among those needing a Papanicolaou test, 211 women received screening referrals. Women in the navigator group (21 of 71, 29.6%) reported higher rates of contacting a Papanicolaou test referral than those exposed to verbal referral only (11/73, 15.1%) or verbal referral and tailored print reminder (9/67, 13.4%) (P=.03). Among 176 women with ≥2 unmet needs who received a Papanicolaou test referral, the provision of a navigator remained associated with contacting the referral (navigator [33.9%] vs verbal referral [17.2%] vs tailored reminder [10.2%]; P=.005). Assignment to the navigator group (adjusted odds ratio, 3.4; 95% confidence interval, 1.4-8.5) and nonwhite race (adjusted odds ratio, 2.0; 95% confidence interval, 1.5-2.8) were independent predictors of contacting a Papanicolaou test referral. CONCLUSION: Low-income women seeking assistance with basic needs often lack cervical cancer screening. Health navigators triple the likelihood that women will make contact with Papanicolaou test services, but most 2-1-1 callers still fail to schedule Papanicolaou testing despite assistance from navigators. Interventions beyond health navigators are needed to reduce cervical cancer disparities.

Improving Lifestyle Behaviors After Breast Cancer Treatment Among African American Women With and Without Diabetes: Role of Health Care Professionals.

BACKGROUND: Little is known about the effect of health professionals' advice on promoting healthy lifestyle behaviors (diet and exercise) among breast cancer patients. PURPOSE: To identify predictors of receiving lifestyle advice from health professionals and its impact on healthy lifestyle behaviors. METHODS: We used data from a randomized controlled trial of an interactive, cancer-communication video program using African American breast cancer survivor stories for newly diagnosed African American breast cancer patients (Stages 0-III). Participants completed five interviews over 2 years. This intervention did not significantly affect changes in quality-of-life outcomes. In secondary analysis, we examined differences in baseline variables between women with and without diabetes. Logistic regression models identified independent predictors of receiving advice from "a doctor or other health professional" to improve diet and exercise and of self-reported change in diet and exercise habits at 2 year follow-up. RESULTS: Of 193 patients included (85% of 228 enrolled), 53 (28%) had diabetes. At 2 year follow-up, a greater proportion of women with (vs. without) diabetes reported receiving advice by a doctor/health professional to improve their diet (73% vs. 57%, p = .04,). Predictors of receiving dietary advice were obesity, diabetes, and breast-conserving surgery (each p < .05). Women receiving dietary advice were 2.75 times more likely to report improving their diet (95% confidence interval: 1.17, 6.46) at follow-up, but receiving physical activity advice was not significantly associated with patients reporting an increase in exercise. CONCLUSIONS: Although receiving dietary advice predicted dietary improvements, receiving exercise advice did not lead to an increase in physical activity. CLINICAL TRIAL REGISTRATION: Trial Number NCT00929084.

Disseminating a Smoke-free Homes Program to Low Socioeconomic Status Households in the United States Through 2-1-1: Results of a National Impact Evaluation.

INTRODUCTION: Given homes are now a primary source of secondhand smoke (SHS) exposure in the United States, research-tested interventions that promote smoke-free homes should be evaluated in real-world settings to build the evidence base for dissemination. This study describes outcome evaluation results from a dissemination and implementation study of a research-tested program to increase smoke-free home rules through US 2-1-1 helplines. METHODS: Five 2-1-1 organizations, chosen through a competitive application process, were awarded grants of up to $70 000. 2-1-1 staff recruited participants, delivered the intervention, and evaluated the program. 2-1-1 clients who were recruited into the program allowed smoking in the home, lived in households with both a smoker and a nonsmoker or child, spoke English, and were at least 18 years old. Self-reported outcomes were assessed using a pre-post design, with follow-up at 2 months post baseline. RESULTS: A total of 2345 households (335-605 per 2-1-1 center) were enrolled by 2-1-1 staff. Most participants were female (82%) and smokers (76%), and half were African American (54%). Overall, 40.1% (n = 940) reported creating a full household smoking ban. Among the nonsmoking adults reached at follow-up (n = 389), days of SHS exposure in the past week decreased from 4.9 (SD = 2.52) to 1.2 (SD = 2.20). Among the 1148 smokers reached for follow-up, 211 people quit, an absolute reduction in smoking of 18.4% (p < .0001), with no differences by gender. CONCLUSIONS: Among those reached for 2-month follow-up, the proportion who reported establishing a smoke-free home was comparable to or higher than smoke-free home rates in the prior controlled research studies. IMPLICATIONS: Dissemination of this brief research-tested intervention via a national grants program with support from university staff to five 2-1-1 centers increased home smoking bans, decreased SHS exposure, and increased cessation rates. Although the program delivery capacity demonstrated by these competitively selected 2-1-1s may not generalize to the broader 2-1-1 network in the United States, or social service agencies outside of the United States, partnering with 2-1-1s may be a promising avenue for large-scale dissemination of this smoke-free homes program and other public health programs to low socioeconomic status populations in the United States.

Feasibility and Acceptability of an Interactive Cancer-Communication Video Program Using African American Breast Cancer Survivor Stories.

To examine the feasibility and acceptability of an interactive video program of African American breast cancer survivor stories, we explored story reactions among African American women with newly diagnosed breast cancer and associations between patient factors and intervention use. During a randomized controlled trial, patients in the intervention arm completed a baseline/pre-intervention interview, received the video intervention, and completed a post-intervention 1-month follow-up interview. Additional video exposures and post-exposure interviews occurred at 6- and 12-month follow-ups. Multivariable linear mixed-effects models examined interview and clinical data in association with changes in minutes and actions using the program. After Exposure1, 104 of 108 patients allocated to the intervention reported moderate-to-high levels of positive emotional reactions to stories and identification with storytellers. Exposure1 mean usage was high (139 minutes) but declined over time (p <.0001). Patients receiving surgery plus radiation logged about 50 more minutes and actions over 12-month follow-up than patients receiving surgery only (p <.05); patients reporting greater trust in storytellers logged 18.6 fewer actions over time (p =.04). Patients' topical interests evolved, with patients watching more follow-up care and survivorship videos at Exposure3. The intervention was feasible and evaluated favorably. New videos might satisfy patients' changing interests.

Implementing an Evidence-based Tobacco Control Program at Five 2-1-1 Call Centers: An Evaluation Using the Consolidated Framework for Implementation Research.

Introduction: The Smoke-Free Homes (SFH) Program is an evidence-based intervention offered within 2-1-1 information and referral call centers to promote smoke-free homes in low-income populations. We used the Consolidated Framework for Implementation Research to conduct a mixed-methods analysis of facilitators and barriers to scaling up SFH to five 2-1-1 sites in the United States. Methods: Data were collected from staff in 2015-2016 via online surveys administered before (N = 120) and after SFH training (N = 101) and after SFH implementation (N = 79). Semi-structured telephone interviews were conducted in 2016 with 25 staff to examine attitudes towards SFH, ways local context affected implementation, and unintended benefits and consequences of implementing SFH. Results: Post-implementation, 79% of respondents reported that SFH was consistent with their 2-1-1's mission, 70% thought it led to more smoke-free homes in their population, 62% thought it was easy to adapt, and 56% thought participants were satisfied. Composite measures of perceived appropriateness of SFH for 2-1-1 callers and staff positivity toward SFH were significantly lower post-implementation than pre-implementation. In interviews, staff said SFH fit with their 2-1-1's mission but expressed concerns about intervention sustainability, time and resources needed for delivery, and how SFH fit into their workflow. Conclusions: Sites' SFH implementation experiences were affected both by demands of intervention delivery and by SFH's perceived effectiveness and fit with organizational mission. Future implementation of SFH and other tobacco control programs should address identified barriers by securing ongoing funding, providing dedicated staff time, and ensuring programs fit with staff workflow. Implications: Smoke-free home policies reduce exposure to secondhand smoke. Partnering with social service agencies offers a promising way to scale up evidence-based smoke-free home interventions among low-income populations. We found that the SFH intervention was acceptable and feasible among multiple 2-1-1 delivery sites. There were also significant challenges to implementation, including site workflow, desire to adapt the intervention, time needed for intervention delivery, and financial sustainability. Addressing such challenges will aid future efforts to scale up evidence-based tobacco control interventions to social service agencies such as 2-1-1.

Unmet basic needs and health intervention effectiveness in low-income populations.

In the face of unmet basic needs, low SES adults are less likely to obtain needed preventive health services. The study objective was to understand how these hardships may cluster and how the effectiveness of different health-focused interventions might vary across vulnerable population sub-groups with different basic needs profiles. From June 2010-2012, a random sample of low-income adult callers to Missouri 2-1-1 completed a cancer risk assessment and received up to 3 health referrals for needed services (mammography, pap testing, colonoscopy, HPV vaccination, smoking cessation and smoke-free home policies). Participants received either a verbal referral only (N=365), verbal referral+tailored print reminder (N=372), or verbal referral+navigator (N=353). Participants reported their unmet basic needs at baseline and contacts with health referrals at 1-month post-intervention. We examined latent classes of unmet basic needs using SAS. Logistic regression examined the association between latent classes and contacting a health referral, by intervention condition. A 3 class solution best fit the data. For participants with relatively more unmet needs (C2) and those with money needs (C3), the navigator intervention was more effective than the tailored or verbal referral only conditions in leading to health referrals contacts. For participants with fewer unmet basic needs (C1), the tailored intervention was as effective as the navigator intervention. The distribution and nature of unmet basic needs in this sample of low-income adults was heterogeneous, and those with the greatest needs benefitted most from a more intensive navigator intervention in helping them seek needed preventive health services.

Minimal intervention delivered by 2-1-1 information and referral specialists promotes smoke-free homes among 2-1-1 callers: a Texas generalisation trial.

BACKGROUND: Replication of intervention research is reported infrequently, limiting what we know about external validity and generalisability. The Smoke Free Homes Program, a minimal intervention, increased home smoking bans by United Way 2-1-1 callers in randomised controlled trials in Atlanta, Georgia and North Carolina. OBJECTIVE: Test the programme's generalisability-external validity in a different context. METHODS: A randomised controlled trial (n=508) of English-speaking callers from smoking-discordant households (≥1 smoker and ≥1 non-smoker). 2-1-1 Texas/United Way HELPLINE call specialists serving the Texas Gulf Coast recruited callers and delivered three mailings and one coaching call, supported by an online tracking system. Data collectors, blind to study assignment, conducted telephone interviews 3 and 6 months postbaseline. RESULTS: At 3 months, more intervention households reported a smoke-free home (46.6% vs 25.4%, p<0.0001; growth model intent-to-treat OR=1.48, 95% CI 1.241 to 1.772, p<0.0001). At 6 months, self-reported full bans were 62.9% for intervention participants and 38.4% for controls (OR=2.19). Texas trial participants were predominantly women (83%), single-smoker households (76%) and African-American (65%); half had incomes ≤US$10 000/year (50%). Texas recruitment was <50% of the other sites. Fewer callers reported having a smoker in the household. Almost twice the callers with a household smoker declined interest in the programme/study. CONCLUSIONS: Our findings in a region with lower smoking rates and more diverse callers, including English-speaking Latinos, support programme generalisability and convey evidence of external validity. Our recruitment experience indicates that site-specific adjustments might improve recruitment efficiency and reach. TRIAL REGISTRATION NUMBER: NCT02097914, Results.

Examining Interpretations of Graphic Cigarette Warning Labels Among U.S. Youth and Adults.

Few studies have examined how diverse populations interpret warning labels. This study examined interpretations of 9 graphic cigarette warning labels (image plus text) proposed by the U.S. Food and Drug Administration among a convenience sample of youth (ages 13-17) and adults (18+) across the United States. Participants (N = 1,571) completed a cross-sectional survey. Participants were asked to select 1 of 3 plausible interpretations (1 preferred vs. 2 alternative) created by the research team about the particular consequence of smoking addressed in each warning label. Participants also rated each label for novelty, counterarguing, perceived effectiveness, and harm. Smokers reported their thoughts of quitting, self-efficacy, and motivation to quit. Although at least 70% of the sample chose the preferred interpretation for 7 of 9 labels, only 13% of participants chose all 9 preferred interpretations. The odds of selecting the preferred interpretation were lower among African Americans, among those with less education, and for labels perceived as being more novel. Smokers reported greater counterarguing and less perceived effectiveness and harms than nonsmokers, but results were not consistent across all labels and interpretations. The alternative interpretations of cigarette warning labels were associated with lower perceived effectiveness and lower perceived harms of smoking, both of which are important for motivating quit attempts.

Methodological innovations in public health education: transdisciplinary problem solving.

In 2008, the faculty of the Brown School at Washington University in St. Louis designed a Master of Public Health program centered on transdisciplinary problem solving in public health. We have described the rationale for our approach, guiding principles and pedagogy for the program, and specific transdisciplinary competencies students acquire. We have explained how transdisciplinary content has been organized and delivered, how the program is being evaluated, and how we have demonstrated the feasibility of this approach for a Master of Public Health degree.

Reactions to FDA-Proposed Graphic Warning Labels Affixed to U.S. Smokers' Cigarette Packs.

INTRODUCTION: Graphic warning labels have been shown to be more effective than text-only labels in increasing attention and perceived health risks, but most U.S. studies have involved single exposures in laboratory or Internet settings. METHODS: We recruited a convenience sample (N = 202) of U.S. adult smokers from population subgroups with higher rates of smoking and smoking-related deaths who had participated in a larger survey about graphic warning labels. Participants were randomized to get 1 of 9 graphic + text labels or a text-only label. Research staff affixed a warning label sticker to participants' cigarette pack(s) at enrollment. Color graphic labels covered slightly more than the lower half of packs. Black and white labels of current U.S. text-only warnings covered the existing side warning to prompt attention to the label (i.e., attention control). Participants received extra stickers of the same label for subsequent packs, and completed 3 telephone interviews in 1 week. RESULTS: Participants reported low avoidance (<34%) and consistent use of the stickers (91%). Smokers consistently paid more attention to graphic than text-only labels. Only 5 of the 9 graphic warning labels were significantly associated with greater thoughts of health risks. Thinking about quitting and stopping smoking did not differ by label. Qualitative data illustrated differences in the "stickiness," self-referencing, and counterarguments of graphic warning labels. CONCLUSIONS: U.S. smokers' reactions to graphic warning labels on their own packs were similar to other, more controlled studies. Qualitative findings underscore the need for warning labels that encourage self-referential processing without increasing defensive reactions.

Basic needs, stress and the effects of tailored health communication in vulnerable populations.

This study examined whether unmet basic needs (food, housing, personal and neighborhood safety, money for necessities) and perceived stress affect recall of and response to a tailored print intervention one month later. Participants (N = 372) were adults who had called 2-1-1 Missouri between June 2010 and June 2012. A series of path analyses using Mplus were conducted to explore the relationships among basic needs, perceived stress, number of health referrals received in a tailored intervention, recalling the intervention and contacting a health referral. Participants were mainly women (85%) and African-American (59%) with a mean age of 42.2 years (SD = 13.3; range 19-86); 41% had annual household income <$10 000. Unmet basic needs were positively associated with increased levels of perceived stress, which, in turn, were negatively associated with recalling the intervention and calling any of the health referrals provided. Tailored printed interventions may be less effective in populations with acute unmet basic needs. More broadly, the effectiveness of minimal contact behavioral interventions might be enhanced by simultaneous efforts to address unmet basic needs.

Behavioral economics: "nudging" underserved populations to be screened for cancer.

Persistent disparities in cancer screening by race/ethnicity and socioeconomic status require innovative prevention tools and techniques. Behavioral economics provides tools to potentially reduce disparities by informing strategies and systems to increase prevention of breast, cervical, and colorectal cancers. With an emphasis on the predictable, but sometimes flawed, mental shortcuts (heuristics) people use to make decisions, behavioral economics offers insights that practitioners can use to enhance evidence-based cancer screening interventions that rely on judgments about the probability of developing and detecting cancer, decisions about competing screening options, and the optimal presentation of complex choices (choice architecture). In the area of judgment, we describe ways practitioners can use the availability and representativeness of heuristics and the tendency toward unrealistic optimism to increase perceptions of risk and highlight benefits of screening. We describe how several behavioral economic principles involved in decision-making can influence screening attitudes, including how framing and context effects can be manipulated to highlight personally salient features of cancer screening tests. Finally, we offer suggestions about ways practitioners can apply principles related to choice architecture to health care systems in which cancer screening takes place. These recommendations include the use of incentives to increase screening, introduction of default options, appropriate feedback throughout the decision-making and behavior completion process, and clear presentation of complex choices, particularly in the context of colorectal cancer screening. We conclude by noting gaps in knowledge and propose future research questions to guide this promising area of research and practice.