Accelerating evidence reviews and broadening evidence standards to identify effective, promising, and emerging policy and environmental strategies for prevention of childhood obesity.

The childhood obesity epidemic has stimulated the emergence of many policy and environmental strategies to increase healthy eating and active living, with relatively few research recommendations identifying the most effective and generalizable strategies. Yet, local, state, and national decision makers have an urgent need to take action, particularly with respect to lower-income and racial and ethnic populations at greatest risk. With the surge of promising and emerging policy and environmental strategies, this review provides a framework, criteria, and process modeled from existing expert classification systems to assess the strength of evidence for these strategies. Likewise, this review highlights evidence gaps and ways to increase the types and amount of evidence available to inform policy and environmental strategies. These priorities include documenting independent and interdependent effects, determining applicability to different populations and settings, assessing implementation fidelity and feasibility, identifying cumulative benefits and costs, ascertaining impacts on health equity, and tracking sustainability.

Exploring scenarios to dramatically reduce smoking prevalence: a simulation model of the three-part cessation process.

OBJECTIVES: We used a simulation model to analyze whether the Healthy People 2010 goal of reducing smoking prevalence from the current 19.8% rate to 12% by 2010 could be accomplished by increasing quit attempts, increasing the use of treatments, or increasing the effectiveness of treatment. METHODS: We expanded on previous versions of the tobacco control simulation model SimSmoke to assess the effects of an increase in quit attempts, treatment use, and treatment effectiveness to reduce smoking prevalence. In the model, we considered increases in each of these parameters individually and in combination. RESULTS: Individually, 100% increases in quit attempts, treatment use, and treatment effectiveness reduced the projected 2020 prevalence to 13.9%, 16.7%, and 15.9%, respectively. With a combined 100% increase in all components, the goal of a 12% adult smoking prevalence could be reached by 2012. CONCLUSIONS: If we are to come close to reaching Healthy People 2010 goals in the foreseeable future, we must not only induce quit attempts but also increase treatment use and effectiveness. Simulation models provide a useful tool for evaluating the potential to reach public health targets.

Creating physical activity-promoting community environments: time for a breakthrough.

Increasing the amount of physical activity Americans get to recommended levels will require changes in community environments so that people can be more active as part of everyday life. Recent and pending federal legislation can provide the investments and other support necessary to make. These changes also positively address other major challenges we face as a nation, including climate change and the ailing economy.

Increasing the demand for and use of effective smoking-cessation treatments reaping the full health benefits of tobacco-control science and policy gains--in our lifetime.

More adults in the United States have quit smoking than remain current smokers. But 45 million adults (20.9%) continue to smoke, with highest rates among low socioeconomic status (SES), blue-collar, and Native American populations. More than two thirds (70%) of adult smokers want to quit, and approximately 40% make a serious quit attempt each year, but only 20%-30% of quitters use an effective behavioral counseling or pharmacologic treatment. The lowest rates of treatment use are seen in the populations with the highest rates of tobacco use. Fully harvesting the last 4 decades of progress in tobacco-control science and policy to increase smokers' demand for and use of cessation treatments represents an extraordinary opportunity to extend lives and reduce healthcare costs and burden in the next 30-40 years. This paper uses the "push-pull capacity" model as a framework for illustrating strategies to achieve this goal. This model recommends: (1) improving and communicating effective treatments for wide population use; (2) building the capacity of healthcare and other systems to deliver effective treatments; and (3) boosting consumer, health plan, and insurer demand for them through policy interventions shown to motivate and support quitting (e.g., clean indoor-air laws, tobacco tax increases, expanded insurance coverage/reimbursement) and efforts to improve treatment access and appeal, especially for smokers who use them least. Innovations recommended by the National Consumer Demand Roundtable for achieving "breakthrough" improvements in cessation treatment demand and use are described.

The Robert Wood Johnson Foundation Diabetes Initiative: demonstration projects emphasizing self-management.

PURPOSE: The purpose of the Diabetes Initiative of the Robert Wood Johnson Foundation is to demonstrate feasible and sustainable approaches to promoting diabetes self-management in primary care and community settings. METHODS: The Diabetes Initiative of the Robert Wood Johnson Foundation includes 14 demonstration projects in primary care settings and in community-clinical partnerships. Projects serve predominantly indigent populations from varied cultural and linguistic backgrounds in urban, rural, and frontier settings around the United States. This report describes the Initiative, its ecological perspective on self-management, and implications for program development, sustainability, and dissemination. RESULTS: Ecological perspectives stress varied levels of influence ranging from individuals to communities and policies. Based on this, the Initiative has identified key resources and supports for self-management (individualized assessment, collaborative goal setting, enhancing skills, follow-up and support, community resources, and continuity of quality clinical care). Lessons learned include the central roles of community health workers, integration of healthy coping and attention to negative emotion and depression in self-management, community partnerships, approaches to ongoing follow-up and support, organizational factors in sustaining programs, and the utility of a collaborative learning network for program development. Sustainability stresses organizational and policy supports for the program. Dissemination of lessons learned will stress collaboration among interested parties, stimulating consumer understanding and demand for self-management services as central to diabetes care. CONCLUSIONS: The Diabetes Initiative demonstrates that effective self-management programs and supports can be implemented in real-world clinical and community settings, providing models of worthwhile, sustainable programs.

Inferring strategies for disseminating physical activity policies, programs, and practices from the successes of tobacco control.

Efforts at reducing tobacco use in the United States and Canada over the last half century have been amazingly successful. This article examines those efforts in order to identify policies, programs, and practices found useful in tobacco control that might be usefully disseminated to world populations to improve rates of physical activity. Tobacco-control activities began with efforts to influence the individual smoker through public education and counter-advertising. Increasing awareness of the addictive properties of tobacco, industry efforts to manipulate those properties, and to target youth with aggressive advertising, fueled public outrage that supported additional policy changes to include community interventions, legal actions, and restraints against the tobacco industry. The article first examines ways to view the process of transferring knowledge from one enterprise (reducing tobacco consumption) to another (increasing physical activity). Several theories of knowledge generalization and dissemination are explored: transfer, knowledge utilization, application, diffusion, and implementation. The second section identifies the dissemination of tobacco control by means of brief health behavior-change interventions for smoking cessation that have been successfully integrated into primary clinical care. The question of whether similar strategies can be successfully disseminated to increase physical activity is examined in detail. The article then moves on to look at the success of arguably the most successful program in the world at achieving a reduction in tobacco control-the State of California. Finally, we compare and contrast some of the lessons as they have played out in another national context-Canada. In the concluding section, some lessons are identified that we believe may be successfully utilized in societal attempts to increase physical activity in world populations.

Indicators of activity-friendly communities: an evidence-based consensus process.

BACKGROUND: Regular physical activity, even at modest intensities, is associated with many health benefits. Most Americans, however, do not engage in the recommended levels. As practitioners seek ways to increase population rates of physical activity, interventions and advocacy efforts are being targeted to the community level. Yet, advocates, community leaders, and researchers lack the tools needed to assess local barriers to and opportunities for more active, healthy lifestyles. Investigators used a systematic review process to identify key indicators of activity-friendly communities that can assess and improve opportunities for regular physical activity. METHODS: Investigators conducted a comprehensive literature review of both peer-reviewed literature and fugitive information (e.g., reports and websites) to generate an initial list of indicators for review (n=230). The review included a three-tiered, modified Delphi consensus-development process that incorporated input of international, national, state, and local researchers and practitioners from academic institutions, federal and state government agencies, nonprofit organizations, and funding agencies in public health, transportation, urban planning, parks and recreation, and public policy. RESULTS: Ten promising indicators of activity-friendly communities were identified: land use environment, access to exercise facilities, transportation environment, aesthetics, travel patterns, social environment, land use economics, transportation economics, institutional and organizational policies, and promotion. CONCLUSIONS: Collaborative, multidisciplinary approaches are underway to test, refine, and expand this initial list of indicators and to develop measures that communities, community leaders, and policymakers can use to design more activity-friendly community environments.

Does counseling by clinicians improve physical activity? A summary of the evidence for the U.S. Preventive Services Task Force.

PURPOSE: To determine whether counseling adults in primary care settings improves and maintains physical activity levels. DATA SOURCES: The Cochrane Database of Systematic Reviews and Registry of Controlled Trials and the MEDLINE, HealthStar, and Best Evidence databases were searched for papers published from 1994 to March 2002. STUDY SELECTION: Controlled trials, case-control studies, and observational studies that examined counseling interventions aimed at increasing physical activity in general primary care populations were reviewed. The researchers included trials in which 1) a patient's primary care clinician performed some of the counseling intervention; 2) behavioral outcomes (physical activity) were reported; and 3) the study was of "good" or "fair" quality, according to criteria developed by the U.S. Preventive Services Task Force. DATA EXTRACTION: Data were abstracted on design and execution, quality, providers, patients, setting, counseling intervention, and self-reported physical activity at follow-up. DATA SYNTHESIS: Eight trials involving 9054 adults met the inclusion criteria. Among six controlled trials with a usual care control group, the effects of counseling on physical activity were mixed. Because most studies had at least one methodologic limitation, it was difficult to rigorously assess the efficacy of the interventions. More research is needed to clarify the effect, benefits, and potential harms of counseling patients in primary care settings to increase physical activity. CONCLUSION: Evidence is inconclusive that counseling adults in the primary care setting to increase physical activity is effective.

Screening for depression in adults: a summary of the evidence for the U.S. Preventive Services Task Force.

PURPOSE: To clarify whether screening adults for depression in primary care settings improves recognition, treatment, and clinical outcomes. DATA SOURCES: The MEDLINE database was searched from 1994 through August 2001. Other relevant articles were located through other systematic reviews; focused searches of MEDLINE from 1966 to 1994; the Cochrane depression, anxiety, and neurosis database; hand searches of bibliographies; and extensive peer review. STUDY SELECTION: The researchers reviewed randomized trials conducted in primary care settings that examined the effect of screening for depression on identification, treatment, or health outcomes, including trials that tested integrated, systematic support for treatment after identification of depression. DATA EXTRACTION: A single reviewer abstracted the relevant data from the included articles. A second reviewer checked the accuracy of the tables against the original articles. DATA SYNTHESIS: Compared with usual care, feedback of depression screening results to providers generally increased recognition of depressive illness in adults. Studies examining the effect of screening and feedback on treatment rates and clinical outcomes had mixed results. Many trials lacked power to detect clinically important differences in outcomes. Meta-analysis suggests that overall, screening and feedback reduced the risk for persistent depression (summary relative risk, 0.87 [95% CI, 0.79 to 0.95]). Programs that integrated interventions aimed at improving recognition and treatment of patients with depression and that incorporated quality improvements in clinic systems had stronger effects than programs of feedback alone. CONCLUSION: Compared with usual care, screening for depression can improve outcomes, particularly when screening is coupled with system changes that help ensure adequate treatment and follow-up.

Predictors of change on the smoking uptake continuum among adolescents.

CONTEXT: Understanding how advertising and other risk and demographic factors affect adolescent susceptibility to smoking would allow for the development of more effective youth-targeted tobacco prevention and cessation programs and policies. OBJECTIVE: To examine the effect of various demographic and risk factors on different stages of smoking among adolescents. DESIGN: A nationally representative cross-sectional survey, The Robert Wood Johnson Foundation's Survey of Tobacco Price Sensitivity, Behavior, and Attitudes Among Teenagers and Young Adults. SUBJECTS: The Robert Wood Johnson Foundation's Survey of Tobacco Price Sensitivity, Behavior, and Attitudes Among Teenagers and Young Adults included 17,287 adolescent respondents (aged, 13-19 years) in 1996. MAIN OUTCOME MEASURES: Stage of susceptibility and correlates of progression toward regular smoking. RESULTS: Of all never [corrected] smoking adolescents, 32% were susceptible smokers (have never smoked, but might) with younger adolescents almost 3 times more likely than older adolescents to be susceptible. Female subjects were 50% [corrected] more likely than male subjects to be susceptible. In addition to exposure to others' smoking, owning or willingness to own tobacco promotional items, having a favorite cigarette advertisement, skipping school, poor school performance, and lack of attendance in religious activities were associated with progression along the uptake continuum. CONCLUSIONS: Improved understanding of the tobacco use trajectories of adolescents and the risk factors associated with progression will help clinicians and tobacco control advocates create effective youth-targeted interventions and policies. Findings suggest that physicians and other health care providers should redouble their efforts to ask preadolescents and young adults about smoking or the likelihood of their smoking. Nonsmokers should also be advised about the addictive nature of tobacco products and the resulting loss of control that accompanies addiction.

Physician screening for multiple behavioral health risk factors.

BACKGROUND: Screening rates in primary care for single behavioral health risk factors are widely documented. However, such risk factors cluster in individuals and populations. This article examines the number and types of behavioral risk factors that U.S. adults reported, and reported having been screened for in their last routine medical checkup. METHODS: The sample consisted of 16,818 adults from the 1998 National Health Interview Survey who reported having a routine checkup in the past year. Respondents completed questions regarding four behavioral risk factors (physical inactivity, overweight, cigarette smoking, risky drinking), and provider screening for behaviors related to these risk factors. RESULTS: Half of the sample (52.0%) reported having two or more of the four risk factors, and more than half (59.4%) were screened for two or more risk behaviors during their last routine checkup, although 28.6% reported being screened for none of them. Respondents reporting at least one risk factor were screened for an average of 57.7% of their own risk factors. Women, adults with lower levels of income and education, and those aged 65 and older, reported being screened for fewer of their risk factors. CONCLUSIONS: While guidelines for risk factor screening and intervention typically focus on single behavioral risk factors, most primary care patients present with, and are screened for, more than one. Behavioral risk factor screening tools and interventions must be expanded to cover multiple risks. Additionally, efforts are needed to reduce the substantial missed opportunities for screening, and to eliminate demographic disparities in screening practices and accuracy.

Evaluating primary care behavioral counseling interventions: an evidence-based approach.

Risky behaviors are a leading cause of preventable morbidity and mortality, yet behavioral counseling interventions to address them are underutilized in healthcare settings. Research on such interventions has grown steadily, but the systematic review of this research is complicated by wide variations in the organization, content, and delivery of behavioral interventions and the lack of a consistent language and framework to describe these differences. The Counseling and Behavioral Interventions Work Group of the United States Preventive Services Task Force (USPSTF) was convened to address adapting existing USPSTF methods to issues and challenges raised by behavioral counseling intervention topical reviews. The systematic review of behavioral counseling interventions seeks to establish whether such interventions addressing individual behaviors improve health outcomes. Few studies directly address this question, so evidence addressing whether changing individual behavior improves health outcomes and whether behavioral counseling interventions in clinical settings help people change those behaviors must be linked. To illustrate this process, we present two separate analytic frameworks derived from screening topic tools that we developed to guide USPSTF behavioral topic reviews. No simple empirically validated model captures the broad range of intervention components across risk behaviors, but the Five A's construct-assess, advise, agree, assist, and arrange-adapted from tobacco cessation interventions in clinical care provides a workable framework to report behavioral counseling intervention review findings. We illustrate the use of this framework with general findings from recent behavioral counseling intervention studies. Readers are referred to the USPSTF (www.ahrq.gov/clinic/prevenix.htm or 1-800-358-9295) for systematic evidence reviews and USPSTF recommendations based on these reviews for specific behaviors.

Physician and enrollee knowledge of Medicaid coverage for tobacco dependence treatments.

BACKGROUND: The 2000 Public Health Service Clinical Practice Guideline, Treating Tobacco Use and Dependence, recommends health insurance coverage for tobacco-dependence treatments proven effective in helping smokers to quit. Two states with comprehensive coverage for tobacco-dependence treatments in their Medicaid programs were selected to document awareness of coverage for tobacco-dependence treatments among primary care physicians who treat Medicaid enrollees and Medicaid-enrolled smokers. METHODS: In 2000, surveys were conducted among Medicaid smokers (n =400) and physicians (n =160) to document knowledge of covered tobacco-dependence treatments under state Medicaid programs in two states with comprehensive coverage. RESULTS: Only 36% of Medicaid-enrolled smokers and 60% of Medicaid physicians knew that their state Medicaid program offered any coverage for tobacco-dependence treatments. Physicians were more than twice as likely to know that pharmacotherapies were covered compared to counseling. CONCLUSIONS: Greater effort is needed to make Medicaid smokers and physicians aware that effective pharmacotherapies and counseling services are available to assist in treating tobacco dependence. Additionally, future research should explore the methods that are most effective in informing patients and providers regarding covered benefits.

Counseling to promote a healthy diet in adults: a summary of the evidence for the U.S. Preventive Services Task Force.

OBJECTIVE: The purpose of this study was to examine the effectiveness of counseling to promote a healthy diet among patients in primary care settings. DESIGN AND DATA SOURCES: We conducted a MEDLINE search from 1966 to December 2001. STUDY SELECTION: We included randomized controlled trials of at least 3 months' duration with measures of dietary behavior that were conducted in patient populations similar to those found in primary care practices. We excluded studies that reported only biochemical or anthropomorphic endpoints, had dropout rates greater than 50%, or enrolled patients based on the presence of a chronic disease. DATA EXTRACTION: One author extracted relevant data from each included article into evidence tables. Using definitions developed by the research team, two authors independently rated each study in terms of its effect size, the intensity of its intervention, the patient risk level, and the use of well-proven counseling techniques. DATA SYNTHESIS: We identified 21 trials for use in this review. Dietary counseling produces modest changes in self-reported consumption of saturated fat, fruits and vegetables, and possibly dietary fiber. More-intensive interventions were more likely to produce important changes than brief interventions, but they may be more difficult to apply to typical primary care patients. Interventions using interactive health communications, including computer-generated telephone or mail messages, can also produce moderate dietary changes. CONCLUSIONS: Moderate- or high-intensity counseling interventions, including use of interactive health communication tools, can reduce consumption of saturated fat and increase intake of fruit and vegetable. Brief counseling of unselected patients by primary care providers appears to produce small changes in dietary behavior, but its effect on health outcomes is unclear.

Prevention and health promotion: decades of progress, new challenges, and an emerging agenda.

Daily habits (e.g., smoking, diet, and exercise) and their immediate consequences (e.g., obesity) confer risk for most of the major health problems in industrialized nations. Hence, determinants of these behaviors and their modifications have been central topics in health psychology. Considerable scientific and applied progress has been made, but the field faces important challenges and opportunities in the future. These challenges and opportunities include changes in demographics and patterns of health, the need for a more comprehensive model of the domain of health behavior and prevention, the need to integrate behavioral and psychosocial risk and resilience, the incorporation of new technologies, and addressing a variety of professional and economic barriers to the implementation of prevention in health care.

Adolescents' acquisition of cigarettes through noncommercial sources.

PURPOSE: To examine the association between demographic and smoking behavior variables and the likelihood of acquiring cigarettes through noncommercial sources. The Robert Wood Johnson Foundation's 1996 National Study of Tobacco Price Sensitivity, Behavior, and Attitudes among Teenagers and Young Adults was the data source in this analysis. Respondents were high school students (grades 9 through 12) ages 13 to 19 years. The sample sizes, respondent selection procedures, and weighting procedures were designed to develop national estimates of adolescent smoking behaviors and attitudes. The questionnaire, modeled on previous surveys and input from leading tobacco control experts, was self-administered. Logistic regression was used to model the independent effects of each variable on the outcome while controlling for the influence of all other variables in the model. An inverse relationship was found between age and the likelihood of acquiring cigarettes through noncommercial sources. Females were 58% more likely to acquire cigarettes through noncommercial sources than were males. There were no differences among adolescents of different racial/ethnic groups in acquisition through noncommercial sources. Those who believed that cigarettes were difficult to acquire were more likely to obtain cigarettes by noncommercial means. Although point-of-sale restrictions have been a focal point of tobacco control legislation, these data suggest that younger smokers and those who view commercial purchase to be difficult are not using commercial sources. Therefore, more comprehensive approaches to limiting access may be required to address all sources of adolescents' acquisition. The proliferation of point-of-sale restrictions may have contributed to increases in noncommercial acquisition by creating the impression that cigarettes were more difficult to purchase. This reinforces the need for educational programs, interventions, and policies that more effectively target noncommercial sources of cigarettes.

Promoting the uptake of evidence in clinical practice: a prescription for action.

In many respects, obstetrics, perinatology, and neonatology have been at the forefront in the dissemination and uptake of evidence-based medicine. The work of the Cochrane Collaboration began largely with the need to systematize the evidence on these subjects. Among other organizations, the National Perinatal Information Service and the Vermont Oxford Network represent exemplary efforts to promote the uptake of evidence. With this background and support, the reader should be equipped to use the tools and examples provided in this article to promote evidence-based practice in his or her own practice setting.

Changes in adolescent cigarette-brand preference, 1989 to 1996.

OBJECTIVE: To understand changes in cigarette-brand choice by adolescents in the context of demographic differences and advertising. METHODS: Data from 3 nationally representative cross-sectional surveys of adolescents were analyzed. RESULTS: Marlboro, Camel, and Newport brand cigarettes accounted for over 80% of the cigarettes usually bought by adolescents in 1989, 1993, and 1996. Between 1989 and 1996, Marlboro and Camel market shares changed little, whereas preference for Newport doubled among white and Hispanic adolescents. CONCLUSIONS: Brand preference among adolescents has been steadily concentrated among 3 brands. More attention may need to be focused on mentholated brands given the increase in Newport's market share.