Mechanisms of motivational interviewing in health promotion: a Bayesian mediation analysis.

BACKGROUND: Counselor behaviors that mediate the efficacy of motivational interviewing (MI) are not well understood, especially when applied to health behavior promotion. We hypothesized that client change talk mediates the relationship between counselor variables and subsequent client behavior change. METHODS: Purposeful sampling identified individuals from a prospective randomized worksite trial using an MI intervention to promote firefighters' healthy diet and regular exercise that increased dietary intake of fruits and vegetables (n = 21) or did not increase intake of fruits and vegetables (n = 22). MI interactions were coded using the Motivational Interviewing Skill Code (MISC 2.1) to categorize counselor and firefighter verbal utterances. Both Bayesian and frequentist mediation analyses were used to investigate whether client change talk mediated the relationship between counselor skills and behavior change. RESULTS: Counselors' global spirit, empathy, and direction and MI-consistent behavioral counts (e.g., reflections, open questions, affirmations, emphasize control) significantly correlated with firefighters' total client change talk utterances (rs = 0.42, 0.40, 0.30, and 0.61, respectively), which correlated significantly with their fruit and vegetable intake increase (r = 0.33). Both Bayesian and frequentist mediation analyses demonstrated that findings were consistent with hypotheses, such that total client change talk mediated the relationship between counselor's skills--MI-consistent behaviors [Bayesian mediated effect: αß = .06 (.03), 95% CI = .02, .12] and MI spirit [Bayesian mediated effect: αß = .06 (.03), 95% CI = .01, .13]--and increased fruit and vegetable consumption. CONCLUSION: Motivational interviewing is a resource- and time-intensive intervention, and is currently being applied in many arenas. Previous research has identified the importance of counselor behaviors and client change talk in the treatment of substance use disorders. Our results indicate that similar mechanisms may underlie the effects of MI for dietary change. These results inform MI training and application by identifying those processes critical for MI success in health promotion domains.

Long-term Outcomes of the ATHENA (Athletes Targeting Healthy Exercise & Nutrition Alternatives) Program for Female High School Athletes.

Adolescence and emerging adulthood are critical windows for establishing life-long behaviors. We assessed long-term outcomes of a prospective randomized harm reduction/health promotion program for female high school athletes. The intervention's immediate beneficial effects on diet pill use and unhealthy eating behaviors have been reported; however, tobacco, alcohol and marijuana use were not immediately altered (Elliot et al, 2004). One to three years following graduation, positive benefits in those domains became evident, and intervention students reported significantly less lifetime use of cigarettes, marijuana, and alcohol. Sport teams may be effective vehicles for gender-specific interventions to promote competency skills and deter harmful actions, and those benefits may manifest when acquired abilities are applied in new environments following high school graduation.

A qualitative study of a nutrition working group.

The Behavioral Change Consortium (BCC) Nutrition Workgroup (NWG) is a multidisciplinary collaboration of representatives from BCC sites and federal agencies. Its mission is to improve measurement of dietary variables. This article presents findings from a qualitative study of perceived effectiveness of the workgroup collaboration. Twelve in-depth interviews were conducted and examined for common themes using the constant comparison method. Themes contributing to perceived effectiveness included: funding and additional resources; invested, committed, and collegial members; strong leadership, clearly articulated goals, and regular communication. Influences seen as reducing effectiveness were: distance, disparate nature of the studies, limited time, and problems associated with starting collaboration after the primary studies had begun data collection. NWG members felt that the workgroup would continue to be successful; however, there were concerns about responsibility for writing and authorship of manuscripts and the need for continued funding to ensure full participation and productivity.

Definition and outcome of a curriculum to prevent disordered eating and body-shaping drug use.

Almost one half of male and female students participate in high school-sponsored athletics, and high school also is a time when classroom health promotion curricula are less effective. The Athletes Training and Learning to Avoid Steroids is a sport team-centered drug-use prevention program for male high school athletes, which has been shown to reduce alcohol and illicit drug use. Just as anabolic steroid use is associated with male athletes, female sport participants may be at a greater risk for disordered eating and body-shaping drug use. Extending sport team-centered programs to young women athletes required defining and ranking factors related to developing those harmful behaviors. Survey results from a cross-sectional cohort of female middle and high school student athletes were used to identify and prioritize potential curriculum components, including mood and self-esteem, norms of behavior, perceptions of healthy body weight, effects of media depictions of women, and societal pressures to be thin. The derived sport team-centered program was prospectively assessed among a second group of female student athletes from 18 high schools, randomized to receive the intervention or the usual care control condition. The Athletes Targeting Healthy Exercise and Nutrition Alternatives (ATHENA) intervention is a scripted, coach-facilitated, peer-led 8-session program, which was incorporated into a team's usual training activities. The ATHENA program significantly altered the targeted risk factors and reduced ongoing and new use of diet pills and body-shaping substances (amphetamines, anabolic steroids, and sport supplements). These findings illustrate the utility of a structured process to define curriculum content, and the program's positive results also confirm the sport team's potential as a vehicle to effectively deter health-harming behaviors.

Preventing substance use and disordered eating: initial outcomes of the ATHENA (athletes targeting healthy exercise and nutrition alternatives) program.

OBJECTIVES: To implement and to assess the efficacy of a school-based, sport team-centered program to prevent young female high school athletes' disordered eating and body-shaping drug use. DESIGN AND SETTING: Prospective controlled trial in 18 high schools, with balanced random assignment by school to the intervention and usual-care control conditions. PARTICIPANTS: We enrolled 928 students from 40 participating sport teams. Mean age was 15.4 years, 92.2% were white, and follow-up retention was 72%. INTERVENTION: The ATHENA (Athletes Targeting Healthy Exercise and Nutrition Alternative) curriculum's 8 weekly 45-minute sessions were incorporated into a team's usual practice activities. Content was gender-specific, peer-led, and explicitly scripted. Topics included healthy sport nutrition, effective exercise training, drug use and other unhealthy behaviors' effects on sport performance, media images of females, and depression prevention. MAIN OUTCOME MEASURES: We assessed participants by confidential questionnaire prior to and following their sport season. We determined program effects using an analysis of covariance-based approach within the Generalized Estimating Equation framework. RESULTS: Experimental athletes reported significantly less ongoing and new use of diet pills and less new use of athletic-enhancing substances (amphetamines, anabolic steroids, and sport supplements) (P<.05 for each). Other health-harming actions also were reduced (less riding with an alcohol-consuming driver [P = .05], more seat belt use [P<.05], and less new sexual activity [P<.05]). The ATHENA athletes had coincident positive changes in strength-training self-efficacy (P<.005) and healthy eating behaviors (P<.001). Reductions occurred in intentions toward future use of diet pills (P<.05), vomiting to lose weight (P<.05), and use of tobacco (P<.05) and muscle-building supplements (P<.005). The program's curriculum components were altered appropriately (controlling mood [P<.005], refusal skills [P = .05], belief in the media [P<.005], and perceptions of closest friends' body-shaping drug use [P<.001]). CONCLUSIONS: Sport teams are effective natural vehicles for gender-specific, peer-led curricula to promote healthy lifestyles and to deter disordered eating, athletic-enhancing substance use, and other health-harming behaviors.

Worksite wellness program implementation: a model of translational effectiveness.

Occupational health promotion programs with documented efficacy have not penetrated worksites. Establishing an implementation model would allow focusing on mediating aspects to enhance installation and use of evidence-based occupational wellness interventions. The purpose of the study was to implement an established wellness program in fire departments and define predictors of program exposure/dose to outcomes to define a cross-sectional model of translational effectiveness. The study is a prospective observational study among 12 NW fire departments. Data were collected before and following installation, and findings were used to conduct mediation analysis and develop a translational effectiveness model. Worker age was examined for its impact. Leadership, scheduling/competing demands, and tailoring were confirmed as model components, while organizational climate was not a factor. The established model fit data well (χ (2)(9) = 25.57, CFI = 0.99, RMSEA = 0.05, SRMR = 0.03). Older firefighters, nearing retirement, appeared to have influences that both enhanced and hindered participation. Findings can inform implementation of worksite wellness in fire departments, and the prioritized influences and translational model can be validated and manipulated in these and other settings to more efficiently move health promotion science to service.

Body mass index as a predictor of firefighter injury and workers' compensation claims.

OBJECTIVE: To determine the relationship between lifestyle variables including body mass index and filing a workers' compensation claim due to firefighter injury. METHODS: A cross-sectional evaluation of firefighter injury related to workers" compensation claims occurring 5 years after the original Promoting Healthy Lifestyles: Alternative Models' Effects study intervention. RESULTS: A logistic regression analysis for variables predicting filing a workers' compensation claim due to an injury was performed with a total of 433 participants. The odds of filing a compensation claim were almost 3 times higher for firefighters with a body mass index of more than 30 kg/m than firefighters with a normal body mass index (odds ratio, 2.89; P < 0.05). CONCLUSIONS: This study addresses a high-priority area of reducing firefighter injuries and workers' compensation claims. Maintaining a healthy body weight is important to reduce injury and workers' compensation claims among firefighters.

Worksite health promotion in six varied US sites: beta testing as a needed translational step.

BACKGROUND: Dissemination of health promotion interventions generally has followed an efficacy, effectiveness to full scale paradigm, and most programs have failed to traverse that sequence. OBJECTIVE: Report national dissemination of a health promotion program and juxtapose sequential case study observations with the current technology transfer literature. DESIGN: Multiple department-level case studies using contact logs, transcribed interactions, augmented with field notes and validated by respondent review; at least two investigators independently generated site summaries, which were compared to formulate a final report. RESULTS: Adoption was facilitated with national partners and designing branded materials. Critical site influences included departmental features, local champions, and liaison relationships. Achieving distal reach and fidelity required sequential process and program revisions based on new findings at each site. CONCLUSIONS: Beta testing to redesign program elements and modify process steps appears to be a needed and often ignored translational step between efficacy and more widespread dissemination.

Mediation analyses: applications in nutrition research and reading the literature.

Mediation analysis is a newer statistical tool that is becoming more prominent in nutrition research. Its use provides insight into the relationship among variables in a potential causal chain. For intervention studies, it can define the influence of different programmatic components and, in doing so, allows investigators to identify and refine a program's critical aspects. We present an overview of mediation analysis, compare mediators with other variables (confounders, moderators, and covariates), and illustrate how mediation analysis permits interpretation of the change process. A framework is outlined for the critical appraisal of articles purporting to use mediation analysis. The framework's utility is demonstrated by searching the nutrition literature and identifying articles citing mediation cross referenced with the terms "nutrition," "diet," "food," and "obesity." Seventy-two articles were identified that involved human subjects and behavior outcomes, and almost half mentioned mediation without tests to define its presence. Tabulation of the 40 articles appropriately assessing mediation demonstrates an increase in these techniques' appearance and the breadth of nutrition topics addressed. Mediation analysis is an important new statistical tool. Familiarity with its methodology and a framework for assessing articles will allow readers to critically appraise the literature and make informed independent evaluations of works using these techniques.

The IGNITE (investigation to guide new insight into translational effectiveness) trial: Protocol for a translational study of an evidenced-based wellness program in fire departments.

BACKGROUND: Worksites are important locations for interventions to promote health. However, occupational programs with documented efficacy often are not used, and those being implemented have not been studied. The research in this report was funded through the American Reinvestment and Recovery Act Challenge Topic 'Pathways for Translational Research,' to define and prioritize determinants that enable and hinder translation of evidenced-based health interventions in well-defined settings. METHODS: The IGNITE (investigation to guide new insights for translational effectiveness) trial is a prospective cohort study of a worksite wellness and injury reduction program from adoption to final outcomes among 12 fire departments. It will employ a mixed methods strategy to define a translational model. We will assess decision to adopt, installation, use, and outcomes (reach, individual outcomes, and economic effects) using onsite measurements, surveys, focus groups, and key informant interviews. Quantitative data will be used to define the model and conduct mediation analysis of each translational phase. Qualitative data will expand on, challenge, and confirm survey findings and allow a more thorough understanding and convergent validity by overcoming biases in qualitative and quantitative methods used alone. DISCUSSION: Findings will inform worksite wellness in fire departments. The resultant prioritized influences and model of effective translation can be validated and manipulated in these and other settings to more efficiently move science to service.