Evidence-Based Intervention (EBI) Mapping: a systematic approach to understanding the components and logic of EBIs.

BACKGROUND: Despite the development of numerous evidence-based interventions (EBIs), many go unused in practice. Hesitations to use existing EBIs may be due to a lack of understanding about EBI components and what it would take to adapt it or implement it as designed. To improve the use of EBIs, program planners need to understand their goals, core components, and mechanisms of action. This paper presents EBI Mapping, a systematic approach based on Intervention Mapping, that can be used to understand and clearly describe EBIs, and help planners put them into practice. METHODS: We describe EBI Mapping tasks and provide an example of the process. EBI Mapping uses principles from Intervention Mapping, a systematic framework for planning multilevel health promotion interventions. EBI Mapping applies the Intervention Mapping steps retrospectively to help planners understand an existing EBI (rather than plan a new one). We explain each EBI Mapping task and demonstrate the process using the VERB Summer Scorecard (VSS), a multi-level community-based intervention to improve youth physical activity. RESULTS: EBI Mapping tasks are: 1) document EBI materials and activities, and their audiences, 2) identify the EBI goals, content, and mechanisms of action, 3) identify the theoretical change methods and practical applications of those methods, 4) describe design features and delivery channels, and 5) describe the implementers and their tasks, implementation strategies, and needed resources. By applying the EBI Mapping tasks, we created a logic model for the VSS intervention. The VSS logic model specifies the links between behavior change methods, practical applications, and determinants for both the at-risk population and environmental change agents. The logic model also links the respective determinants to the desired outcomes including the health behavior and environmental conditions to improve the health outcome in the at-risk population. CONCLUSIONS: EBI Mapping helps program planners understand the components and logic of an EBI. This information is important for selecting, adapting, and scaling-up EBIs. Accelerating and improving the use of existing EBIs can reduce the research-to-practice gap and improve population health.

Are Training and Experience Adapting Evidence-Based Interventions Associated With Self-Efficacy and Attitudes? A Cross-Sectional Survey of Students and Practitioners With Varying Levels of Adaptation Experience.

Increasing use of evidence-based interventions (EBIs) in local settings will help reduce the research-practice gap and improve health equity. Because adaptation to new settings and populations is essential to effective EBI use, frameworks to guide practice are receiving more attention; most, however, only provide broad guidelines without instructions for making adaptations in practice. Therefore, practitioners may need additional training or technical assistance (TA) to implement and adapt EBIs. This study explores whether practitioners' and students' general EBI training or TA and level of adaptation experience are associated with self-efficacy in adapting EBIs and with attitudes toward EBI use. We analyzed baseline survey data of participants in an evaluation of IM-Adapt Online, a newly developed decision support tool. We asked about previous training on EBIs, general and specific adaptation behaviors, and attitudes toward EBIs and found an association between previous training or TA in using EBIs with higher self-efficacy for using and adapting EBIs. Respondents with prior EBI training were significantly more likely to have higher self-efficacy in EBI behaviors across subdomains and in total than those without training. Respondents reported lowest self-efficacy for planning adaptations (M = 3.35) and assessing fit of EBIs to their local context (M = 3.41). This study suggests the importance of EBI adaptation training and TA to increase adoption and adaptation of EBIs, subsequently. More adaptation-specific training is warranted to assist students, practitioners, and researchers undertaking the adaptation process and implement EBIs. Future training on EBI adaptation can help practitioners tailor EBIs to meet the specific needs of their populations.

Factors associated with adolescent HPV vaccination in the U.S.: A systematic review of reviews and multilevel framework to inform intervention development.

Multilevel factors impact HPV vaccine series initiation and completion among adolescents in the U.S. Synthesis of these factors is needed to inform intervention development and to direct future research. Current frameworks synthesizing factors focus on females only and do not include both series initiation and completion outcomes. We conducted a systematic review of reviews to identify modifiable individual-, provider-, and clinic-level factors associated with HPV vaccination outcomes among U.S. adolescents and developed a multilevel framework illustrating relations between factors to inform intervention development. We searched Medline, PsychInfo, Pubmed, CINAHL, and ERIC databases and included reviews published 2006 to July 2, 2018 describing individual-, provider-, or clinic-level factors quantitatively associated with HPV vaccination among U.S. adolescents. Two coders independently screened reviews, extracted data, and determined quality ratings. Sixteen reviews containing 481 unique primary studies met criteria. Factors synthesized into the multilevel framework included parent psychosocial factors (knowledge, beliefs, outcome expectations, intentions) and behaviors, provider recommendation, and patient-targeted and provider-targeted clinic systems. The scope of our framework and review advances research in two key ways. First, the framework illustrates salient modifiable factors at multiple levels on which to intervene to increase HPV vaccination. Second, the review identified critical gaps in the literature at each level. Future research should link the body of literature on parental intentions to vaccination outcomes, identify provider psychosocial factors associated with recommendation behaviors and subsequent vaccine uptake in their patient population, and understand clinic factors associated with successful implementation of patient- and provider-targeted system-level interventions.

Antiretroviral therapy maintenance among HIV-positive women in Ghana: the influence of poverty.

This study examines the role of poverty in the acquisition of and the adherence to antiretroviral therapy (ART) and prescribed clinical follow-up regimens among HIV-positive women. We conducted in-depth interviews with 40 women living with HIV (WLHIV) in Ghana and 15 stakeholders with a history of work in HIV-focused programs. Our findings indicate that financial difficulty contributed to limited ability to maintain treatment, the recommended nutrient-rich diet, and clinical follow-up schedules. However, enacted stigma and concurrent illness of family members also influenced the ability of the WLHIV to generate income; therefore, HIV infection itself contributed to poverty. To further examine the relation between finances, ART adherence, and the maintenance of recommended clinical follow-up, we present the perspectives of several HIV-positive peer counselor volunteers in Ghana's Models of Hope program. We recommend that programs to combat stigma continue to be implemented, as decreased stigma may reduce the financial difficulties of HIV-positive individuals. We also recommend enhancing current support programs to better assist peer counselor volunteers, as their role directly supports Ghana's national strategic HIV/AIDS plan. Finally, additional investment in poverty-reduction across Ghana, such as broadening meal assistance beyond the currently limited food programs, would lighten the load of those struggling to combat HIV and meet basic needs.

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.

Moderators of Establishing a Smoke-Free Home: Pooled Data from Three Randomized Controlled Trials of a Brief Intervention.

Interventions to create smoke-free homes typically focus on parents, involve multiple counseling sessions and blend cessation and smoke-free home messages. Smoke-Free Homes: Some Things are Better Outside is a minimal intervention focused on smokers and nonsmokers who allow smoking in the home, and emphasizes creation of a smoke-free home over cessation. The purpose of this study is to conduct moderator analyses using pooled data from three randomized controlled trials of the intervention conducted in collaboration with 2-1-1 contact centers in Atlanta, North Carolina and Houston. 2-1-1 is a strategic partner for tobacco control as it connects over 15 million clients, largely socio-economically disadvantaged, to social and health resources each year. A total of 1506 2-1-1 callers participated across the three intervention trials. Outcomes from 6 months intent-to-treat analyses were used to examine whether sociodemographic variables and smoking-related characteristics moderated effectiveness of the intervention in establishing full home smoking bans. Intervention effectiveness was not moderated by race/ethnicity, education, income, children in the home or number of smokers in the home. Smoking status of the participant, however, did moderate program effectiveness, as did time to first cigarette. Number of cigarettes per day and daily versus nondaily smoking did not moderate intervention effectiveness. Overall, the intervention was effective across socio-demographic groups and was effective without respect to daily versus nondaily smoking or number of cigarettes smoked per day, although smoking status and level of nicotine dependence did influence effectiveness.

Considerations for purposeful HIV status disclosure among women living with HIV in Ghana.

Although disclosure of positive HIV status has recognized benefits, enacted and perceived stigma is a continuing problem in Ghana, especially affecting women living with HIV (WLHIV). This qualitative study investigates how WLHIV make these decisions. We interviewed 40 WLHIV, analysing their transcripts using thematic content analysis. Four themes emerged from the data: selectivity in disclosure; disclosure for education, prevention and to provide support; concern for the potential confident, and safety in secrets. Women's awareness of and concerns about HIV-related stigma led them to seriously weigh the costs and benefits of disclosure decisions. Overall, our participants disclosed only when they believed that disclosure would benefit them or the confidant. They did not condone open disclosure, and preferred non-disclosure to minimize harm to themselves and loved ones. Though disclosure occurred for HIV education and prevention purposes, personal safety was the priority. We recommend revision of current post-HIV testing and pre-treatment counselling procedures to incorporate WLHIVs' judgements about disclosure and discussion of the perceived benefits of disclosure. Disclosure is an intricate process that involves support seeking and educating others while averting harm. Continued research of the factors related to disclosure is important to enhance understanding of the disclosure process.

A Qualitative Study Among Mexican Americans to Understand Factors Influencing the Adoption and Enforcement of Home Smoking Bans.

INTRODUCTION: One-third of Mexican-American children, in addition to nonsmoker adults, are exposed to secondhand smoke at home, yet few interventions target Mexican-American households. An effective, brief English language program, tested with United Way 2-1-1 callers in Atlanta, increased home smoking bans (confirmed by air monitors). Two randomized controlled trials in North Carolina and Texas replicated those results. We explored factors determining adoption and enforcement of smoking bans in Mexican-American households to inform program linguistic and cultural adaptation to broaden program reach and relevance. METHODS: Bilingual interviewers recruited convenience samples of Mexican-American smokers and nonsmokers living with at least one smoker in Houston and San Diego households and asked open-ended questions regarding conditions for implementing home and vehicle smoking bans and conditions for varying acceptance of bans. Investigators independently reviewed English transcripts and completed a descriptive analysis using ATLAS.ti. RESULTS: Participants (n = 43) were predominantly female (n = 31), current smokers (n = 26), interviewed in Spanish (n = 26), had annual household incomes less than $30000 (n = 24), and allowed smoking inside the home (n = 24). Themes related to difficulty creating and enforcing bans included courtesy, respect for guests and heads of household who smoke, and gender imbalances in decision making. Participants viewed protecting children's health as a reason for the ban but not protecting adult nonsmokers' health. CONCLUSION: A dual-language, culturally adapted intervention targeting multigenerational Mexican-American households should address household differences regarding language and consider influences of cultural values on family dynamics and interactions with guests that may weaken bans. IMPLICATIONS: Qualitative interviews suggested cultural and family considerations to address in adapting a brief evidence-based smoke-free homes intervention for Mexican Americans, including traditional gender roles, unique contexts of multigenerational households, and language preferences. Our work confirms previous research among Latinos regarding importance of common cultural constructs, such as respeto (deference), simpatia (courtesy and agreeability), and familismo (family attachment), which inform behaviors that may impede or facilitate adopting and enforcing home smoking bans. Decision-making gender imbalances, high regard for head-of-household and guest smokers, and less sensitivity to the health of nonsmoker adults compared with children may lead to permission to smoke indoors.

HIV antiretroviral medication stock-outs in Ghana: contributors and consequences.

Drug stock-outs are an unfortunate yet common reality for patients living in low and middle income countries, particularly in sub-Saharan Africa where trouble with consistent stock of antiretroviral medications (ARVs) continues. Our study takes a snapshot of this problem in Ghana. Although the country launched its antiretroviral therapy (ART) programme in 2003, progress toward realising the full benefit of ART for treated individuals has been limited, in part, because of stock-outs. In Ghana's Greater Accra region, we conducted semi-structured interviews with 40 women living with HIV (WLHIV) and 15 individuals with a history of HIV-related work in government or non-governmental organisations, or healthcare facilities. We used repeated review with coding and mapping techniques to analyse the transcripts and identify common themes. Stock-outs of ARVs result in inconsistent administration of therapy, increased indirect medical costs for WLHIV, and negative labelling of patients. Inefficiencies in drug supply, poor coordination with port authorities, inadequate government funding and dependence on international aid contribute to the stock-outs experienced in Ghana. Although using ARVs produced in-country could reduce supply problems, the domestically-manufactured product currently does not meet World Health Organization (WHO) standards. We recommend focused efforts to produce WHO standard ARVs in Ghana, and a review of current supply chain management to identify and mend pitfalls in the system.

Challenges in Enforcing Home Smoking Rules in a Low-Income Population: Implications for Measurement and Intervention Design.

INTRODUCTION: Smoke-free homes reduce exposure to secondhand smoke, contribute to lower levels of consumption, and help smokers to quit. Even when home smoking rules are established however, they may not be consistently enforced. METHODS: This study uses data from a randomized controlled trial of a brief intervention to create smoke-free homes among callers to the United Way of Greater Atlanta 2-1-1. Participants with partial or full home smoking bans at 6-month follow-up were asked about enforcement challenges, rooms where smoking occurred, and exceptions to the rules. Air nicotine monitors were placed in a subset of homes. RESULTS: Participants (n = 286) were mostly female (84.6%) and African American (84.9%). Most were smokers (79.0%) and reported at least half of their friends and relatives smoked (63.3%). Among those with a full ban, 4.3% reported their rules were broken very often whereas 52.6% stated they were never broken. Bad weather and parties were the most common exceptions to rules. Among nonsmokers with full bans, 16% reported exposure to secondhand smoke in the home 1-3 days in the past week. In multivariate analyses, having a partial ban, being a nonsmoker, and living with three or more smokers predicted higher levels of enforcement challenges. CONCLUSIONS: Findings suggest the majority of households with newly adopted smoke-free rules had no or rare enforcement challenges, but about one-fifth reported their rules were broken sometimes or very often. Interventions to create smoke-free homes should address enforcement challenges as newly adopted rules may be fragile in some households. IMPLICATIONS: Interventions that promote smoke-free homes should address enforcement challenges.

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.

A minimal intervention to promote smoke-free homes among 2-1-1 callers: a randomized controlled trial.

OBJECTIVES: We tested the efficacy of a minimal intervention to create smoke-free homes in low-income households recruited through the United Way of Greater Atlanta 2-1-1, an information and referral system that connects callers to local social services. METHODS: We conducted a randomized controlled trial (n=498) from June 2012 through June 2013, with follow-up at 3 and 6 months. The intervention consisted of 3 mailings and 1 coaching call. RESULTS: Participants were mostly smokers (79.7%), women (82.7%), African American (83.3%), and not employed (76.5%), with an annual household income of $10,000 or less (55.6%). At 6-months postbaseline, significantly more intervention participants reported a full ban on smoking in the home than did control participants (40.0% vs 25.4%; P=.002). The intervention worked for smokers and nonsmokers, as well as those with or without children. CONCLUSIONS: Minimal intervention was effective in promoting smoke-free homes in low income households and offers a potentially scalable model for protecting children and adult nonsmokers from secondhand smoke exposure in their homes.

Designing Normative Messages About Active Surveillance for Men With Localized Prostate Cancer.

Active surveillance is increasingly recognized as a reasonable option for men with low-risk, localized prostate cancer, yet few men who might benefit from conservative management receive it. The authors examined the acceptability of normative messages about active surveillance as a management option for patients with low-risk prostate cancer. Men with a diagnosis of localized prostate cancer who were recruited through prostate cancer support organizations completed a web-based survey (N = 331). They rated messages about active surveillance for believability, accuracy, and importance for men to hear when making treatment decisions. The message "You don't have to panic … you have time to think about your options" was perceived as believable, accurate, and important by more than 80% of the survivors. In contrast, messages about trust in the active surveillance protocol and "knowing in plenty of time" if treatment is needed were rated as accurate by only about 36% of respondents. For active surveillance to be viewed as a reasonable alternative, men will need reassurance that following an active surveillance protocol is likely to allow time for curative treatment if the cancer progresses.

Randomized, controlled pilot trial of bupropion for pregnant smokers: challenges and future directions.

OBJECTIVE: The aim of the study is to conduct an initial pilot trial evaluating the feasibility, safety, and efficacy of bupropion for smoking cessation in pregnancy. STUDY DESIGN: A randomized, double-blind, parallel-group pilot study of bupropion versus placebo with 50 pregnant smokers was planned. Eligibility criteria were restrictive (e.g., 14-26 weeks' gestation; no psychiatric conditions or medications) due to the unknown safety, tolerability, and side effect profile of bupropion in pregnancy. Bayesian analyses were planned to provide probability of benefit. RESULTS: Significant challenges were encountered with regard to trial feasibility. Of 820 women screened, 112 were current smokers, but only 11 women were eligible and consented to participate in the study. Excluded women most often had a psychiatric disorder (23%); were outside the gestational range (14%); or declined to participate (11%). CONCLUSIONS: This initial attempt to evaluate bupropion for smoking cessation during pregnancy will inform future trial methodology. Because of the unknown safety profile, conservative eligibility criteria were used and resulted in a large portion of this high-risk, low-income smoker population being excluded from the trial, raising questions regarding broad applicability, and highlighting the need to balance patient safety and trial feasibility. Large multisite studies will likely be needed to conduct definitive pharmacotherapy studies.

'It's not like you just had a heart attack': decision-making about active surveillance by men with localized prostate cancer.

BACKGROUND: Growing recognition that active surveillance (AS) is a reasonable management option for many men diagnosed with localized prostate cancer led us to describe patients' conceptualizations of AS and reasons for their treatment decisions. METHODS: Men were patients of a multidisciplinary prostate cancer clinic at a large tertiary cancer center where patients are routinely briefed on treatment options, including AS. We conducted a thematic analysis of interviews with 15 men who had chosen AS and 15 men who received radiation or surgery. RESULTS: Men who chose AS described it as an organized process with a rigorous and reassuring protocol of periodic testing, with potential for subsequent and timely decision-making about treatment. AS was seen as prolonging their current good health and function with treatment still possible later. Rationales for choosing AS included trusting their physician's monitoring, 'buying time' without experiencing adverse effects of treatment, waiting for better treatments, and seeing their cancer as very low risk. Men recognized the need to justify their choice to others because it seemed contrary to the impulse to immediately treat cancer. Descriptions of AS by men who chose surgery or radiation were less specific about the testing regimen. Getting rid of the cancer and having a cure were paramount for them. CONCLUSIONS: Men fully informed of their treatment options for localized prostate cancer have a comprehensive understanding of the purpose of AS. Slowing the decision-making process may enhance the acceptability of AS.

Development and pilot testing of an online case-based approach to shared decision making skills training for clinicians.

BACKGROUND: Although research suggests that patients prefer a shared decision making (SDM) experience when making healthcare decisions, clinicians do not routinely implement SDM into their practice and training programs are needed. Using a novel case-based strategy, we developed and pilot tested an online educational program to promote shared decision making (SDM) by primary care clinicians. METHODS: A three-phased approach was used: 1) development of a conceptual model of the SDM process; 2) development of an online teaching case utilizing the Design A Case (DAC) authoring template, a well-tested process used to create peer-reviewed web-based clinical cases across all levels of healthcare training; and 3) pilot testing of the case. Participants were clinician members affiliated with several primary care research networks across the United States who answered an invitation email. The case used prostate cancer screening as the clinical context and was delivered online. Post-intervention ratings of clinicians' general knowledge of SDM, knowledge of specific SDM steps, confidence in and intention to perform SDM steps were also collected online. RESULTS: Seventy-nine clinicians initially volunteered to participate in the study, of which 49 completed the case and provided evaluations. Forty-three clinicians (87.8%) reported the case met all the learning objectives, and 47 (95.9%) indicated the case was relevant for other equipoise decisions. Thirty-one clinicians (63.3%) accessed supplementary information via links provided in the case. After viewing the case, knowledge of SDM was high (over 90% correctly identified the steps in a SDM process). Determining a patient's preferred role in making the decision (62.5% very confident) and exploring a patient's values (65.3% very confident) about the decisions were areas where clinician confidence was lowest. More than 70% of the clinicians intended to perform SDM in the future. CONCLUSIONS: A comprehensive model of the SDM process was used to design a case-based approach to teaching SDM skills to primary care clinicians. The case was favorably rated in this pilot study. Clinician skills training for helping patients clarify their values and for assessing patients' desire for involvement in decision making remain significant challenges and should be a focus of future comparative studies.

Physician behaviors to promote informed decisions for prostate cancer screening: a National Research Network study.

Clinical guidelines for prostate cancer screening (PCS) advise physicians to discuss the potential harms and benefits of screening. However, there is a lack of training programs for informed decision-making (IDM), and it is unknown which IDM behaviors physicians have the most difficulty performing. Identifying difficult behaviors can help tailor training programs. In the context of developing a physician-IDM program for PCS, we aimed to describe physicians' use of nine key IDM behaviors for the PCS discussion and to examine the relation between the behaviors and physician characteristics. A cross-sectional sample of The American Academy of Family Physicians National Research Network completed surveys about their behavior regarding PCS (N = 246; response rate = 58%). The surveys included nine physician key IDM behaviors for PCS and a single-item question describing their general practice style for PCS. The most common IDM behavior was to invite men to ask questions. The two least common reported behaviors concerned patients uncertain about screening (i.e., arrange follow-up and provide additional information for undecided men). Physicians reported difficulty with these two behaviors regardless whether they reported to discuss or not to discuss PCS with patients. Reported use of key IDM behaviors was associated with a general practice style for PCS and being affiliated with a residency-training program. Physician training programs for IDM should include physician skills to address the needs of patients uncertain about screening. Future research should determine if actual behavior is associated with self-reported behavior for the PCS discussion.

Pathways linking socioeconomic status and postpartum smoking relapse.

BACKGROUND: Low socioeconomic status (SES) exacerbates the high rate of smoking relapse in women following childbirth. PURPOSE: This study examined multiple models of potential mechanisms linking SES and postpartum smoking relapse among women who quit smoking due to pregnancy. METHODS: Participants were 251 women enrolled in a randomized clinical trial of a new postpartum smoking relapse prevention intervention. Four models of the prepartum mechanisms linking SES and postpartum smoking relapse were evaluated using a latent variable modeling approach. RESULTS: Each of the hypothesized models were a good fit for the data. As hypothesized, SES indirectly influenced postpartum smoking relapse through increased prepartum negative affect/stress, reduced sense of agency, and increased craving for cigarettes. However, the model that included craving as the sole final pathway between SES and relapse demonstrated superior fit when compared with all other models. CONCLUSIONS: Findings have implications for future interventions that aim to reduce postpartum relapse.

Primary care physicians' use of an informed decision-making process for prostate cancer screening.

PURPOSE: Leading professional organizations acknowledge the importance of an informed decision-making process for prostate cancer screening. We describe primary care physicians' reports of their prescreening discussions about the potential harms and benefits of prostate cancer screening. METHODS: Members of the American Academy of Family Physicians National Research Network responded to a survey that included (1) an indicator of practice styles related to discussing harms and benefits of prostate-specific antigen testing and providing a screening recommendation or letting patients decide, and (2) indicators reflecting physicians' beliefs about prostate cancer screening. The survey was conducted between July 2007 and January 2008. RESULTS: Of 426 physicians 246 (57.7%) completed the survey questionnaire. Compared with physicians who ordered screening without discussion (24.3%), physicians who discussed harms and benefits with patients and then let them decide (47.7%) were more likely to endorse beliefs that scientific evidence does not support screening, that patients should be told about the lack of evidence, and that patients have a right to know the limitations of screening; they were also less likely to endorse the belief that there was no need to educate patients because they wanted to be screened. Concerns about medicolegal risk associated with not screening were more common among physicians who discussed the harms and benefits and recommended screening than among physicians who discussed screening and let their patients decide. CONCLUSIONS: Much of the variability in physicians' use of an informed decision-making process can be attributed to beliefs about screening. Concerns about medicolegal risk remain an important barrier for shared decision making.

A systematic development process for patient decision aids.

BACKGROUND: The original version of the International Patient Decision Aid Standards (IPDAS) recommended that patient decision aids (PtDAs) should be carefully developed, user-tested and open to scrutiny, with a well-documented and systematically applied development process. We carried out a review to check the relevance and scope of this quality dimension and, if necessary, to update it. METHODS: Our review drew on three sources: a) published papers describing PtDAs evaluated in randomised controlled trials and included in the most recent Cochrane Collaboration review; b) linked papers cited in the trial reports that described how the PtDAs had been developed; and c) papers and web reports outlining the development process used by organisations experienced in developing multiple PtDAs. We then developed an extended model of the development process indicating the various steps on which documentation is required, as well as a checklist to assess the frequency with which each of the elements was publicly reported. RESULTS: Key features common to all patient decision aid (PtDA) development processes include: scoping and design; development of a prototype; 'alpha' testing with patients and clinicians in an iterative process; 'beta' testing in 'real life' conditions (field tests); and production of a final version for use and/or further evaluation. Only about half of the published reports on the development of PtDAs that we reviewed appear to have been field tested with patients, and even fewer had been reviewed or tested by clinicians not involved in the development process. Very few described a distribution strategy, and surprisingly few (17%) described a method for reviewing and synthesizing the clinical evidence. We describe a model development process that includes all the original elements of the original IPDAS criterion, expanded to include consideration of format and distribution plans as well as prototype development. CONCLUSIONS: The case for including each of the elements outlined in our model development process is pragmatic rather than evidence-based. Optimal methods for ensuring that each stage of the process is carried out effectively require further development and testing.