Effect of the STAMP (Sharing and Talking About My Preferences) Intervention on Completing Multiple Advance Care Planning Activities in Ambulatory Care : A Cluster Randomized Controlled Trial.

BACKGROUND: Interventions with the potential for broad reach in ambulatory settings are necessary to achieve a life course approach to advance care planning. OBJECTIVE: To examine the effect of a computer-tailored, behavioral health model-based intervention on the engagement of adults in advance care planning recruited from ambulatory care settings. DESIGN: Cluster randomized controlled trial with participant-level analysis. (ClinicalTrials.gov: NCT03137459). SETTING: 10 pairs of primary and selected specialty care practices matched on patient sociodemographic information. PARTICIPANTS: English-speaking adults aged 55 years or older; 454 adults at practices randomly assigned to usual care and 455 at practices randomly assigned to intervention. INTERVENTION: Brief telephone or web-based assessment generating a mailed, individually tailored feedback report with a stage-matched brochure at baseline, 2 months, and 4 months. MEASUREMENTS: The primary outcome was completion of the following 4 advance care planning activities at 6 months: identifying and communicating with a trusted person about views on quality versus quantity of life, assignment of a health care agent, completion of a living will, and ensuring that the documents are in the medical record-assessed by a blinded interviewer. Secondary outcomes were completion of individual advance care planning activities. RESULTS: Participants were 64% women and 76% White. The mean age was 68.3 years (SD, 8.3). The predicted probability of completing all advance care planning activities in usual care sites was 8.2% (95% CI, 4.9% to 11.4%) versus 14.1% (CI, 11.0% to 17.2%) in intervention sites (adjusted risk difference, 5.2 percentage points [CI, 1.6 to 8.8 percentage points]). Prespecified subgroup analysis found no statistically significant interactions between the intervention and age, education, or race. LIMITATIONS: The study was done in a single region and excluded non-English speaking participants. No information was collected about nonparticipants. CONCLUSION: A brief, easily delivered, tailored print intervention increased participation in advance care planning in ambulatory care settings. PRIMARY FUNDING SOURCE: National Institute of Nursing Research and National Institute of Aging.

Psychometric assessment of the processes of change scale for sun protection.

The fourteen-factor Processes of Change Scale for Sun Protection assesses behavioral and experiential strategies that underlie the process of sun protection acquisition and maintenance. Variations of this measure have been used effectively in several randomized sun protection trials, both for evaluation and as a basis for intervention. However, there are no published studies, to date, that evaluate the psychometric properties of the scale. The present study evaluated factorial invariance and scale reliability in a national sample (N = 1360) of adults involved in a Transtheoretical model tailored intervention for exercise and sun protection, at baseline. Invariance testing ranged from least to most restrictive: Configural Invariance (constraints only factor structure and zero loadings); Pattern Identity Invariance (equal factor loadings across target groups); and Strong Factorial Invariance (equal factor loadings and measurement errors). Multi-sample structural equation modeling tested the invariance of the measurement model across seven subgroups: age, education, ethnicity, gender, race, skin tone, and Stage of Change for Sun Protection. Strong factorial invariance was found across all subgroups. Internal consistency coefficient Alpha and factor rho reliability, respectively, were .83 and .80 for behavioral processes, .91 and .89 for experiential processes, and .93 and .91 for the global scale. These results provide strong empirical evidence that the scale is consistent, has internal validity and can be used in research interventions with population-based adult samples.

Intervention Effects on Stage of Change Membership and Transitions among Adolescent Energy Balance Behaviors.

The transition from childhood to adolescence is a crucial period for the development of healthy behaviors to be sustained later in life. With obesity a leading public health problem, the promotion of healthy behaviors has the potential to make a huge impact. The current study evaluated Stage of Change progression in a large (N = 4158) computer-delivered, Transtheoretical Model-tailored intervention focusing on physical activity and fruit and vegetable consumption (FV). Markov models were used to explore stage transitions and patterns of discrete change from sixth to ninth grade. Nested model comparisons examined the consistency of these patterns across time and intervention condition. Major findings supported models in which participants were free to transition forward and backward to any of the stages, but higher probabilities were observed for remaining in the same stage or for transitioning one or two stages forward. Participants in the intervention group had higher probabilities of transitioning toward Maintenance, with more change occurring relative to the comparison group during transitions from grades six to eight but not for grades eight to nine.

Transtheoretical Model Constructs' Longitudinal Prediction of Sun Protection Over 24 Months.

PURPOSE: This research examined dynamic transtheoretical model (TTM) constructs for adopting sun protection practices. This secondary data analysis pooled four large population-based TTM-tailored intervention studies and examined use of constructs across three groups, organized by longitudinal progress: maintainers, relapsers, and stable non-changers. METHODS: A total of 3463 adults, in the USA, who met criteria for unsafe sun exposure at baseline received a TTM-tailored computerized intervention at baseline, 6 months, and 12 months. The final analytic sample consisted of 1894 participants; the majority were female, White, married, and middle-aged. The three groups were assessed with reliable and valid scales assessing use of TTM constructs at baseline, 6 months, 12 months, and 24 months. Analyses included a MANOVA followed by a series of ANOVAs, with Tukey follow-up tests assessing differences in use of TTM constructs across the three groups at each timepoint. RESULTS: Findings demonstrated that relapsers and maintainers were similar in their use of most TTM processes of change at baseline, with the exception of Consciousness Raising, Stimulus Control, Reinforcement Management, and Self-Liberation. CONCLUSIONS: These findings suggest that although relapsers reverted to unsafe sun practices, their overall greater use of processes of change indicates that their change efforts remain better than that of stable non-changers.

Fat Reduction Efforts: A 24-Month Longitudinal Comparison of a Large Sample of Maintainers, Relapsers, and Non-Changers.

This research examined dynamic transtheoretical model (TTM) constructs for dietary fat reduction. This secondary data analysis pooled three large population-based TTM-tailored school, worksite, medical, and home-based intervention studies and examined use of constructs across three groups organized by longitudinal progress (dynatypes): Maintainers, Relapsers, and Stable Non-Changers. The criteria for successful change, at the time, were that less than 30% of calories came from fat. A total of 2,718 adults met criteria for an unhealthy diet at baseline. The majority of participants were female, White, married, and middle-aged. Demographics, Stage of Change, Processes of Change, Decisional Balance, and Temptations were measured. Dynatype groups were assessed with reliable and valid scales assessing constructs at baseline and 6, 12, and 24 months. Analyses included a multivariate analysis of variance followed by a series of analyses of variance, with Tukey follow-up tests assessing differences in use of TTM constructs across the three groups at each time point. Relapsers and Maintainers were similar in their use of all TTM Processes of Change at baseline, with the exception of Self-Liberation (η(2) = 0.15, p < .001) and Reinforcement Management (η(2) = 0.01, p < .001). Although Relapsers reverted to an unhealthy diet, their overall greater use of Processes of Change suggests that their behaviors and strategy use remain better than that of the Stable Non-Changer group. Results suggest that specific cognitive and behavioral constructs may contribute differentially to intervention outcomes.

Sustainable transportation stage of change, decisional balance, and self-efficacy scale development and validation in two university samples.

Single occupancy vehicle (SOV) transportation is a key contributor to climate change and air pollution. Sustainable transportation (ST), commuting by any means other than SOV, could both slow climate change and enhance public health. The transtheoretical model (TTM) provides a useful framework for examining how people progress towards adopting ST. Short valid and reliable measures for ST decisional balance, self-efficacy, and climate change doubt were developed and their relationship with stages of change was examined. Two large university-based volunteer samples participated in measurement studies. Using multiple procedures, three brief internally consistent measures were developed: decisional balance, self-efficacy, and climate change doubt. The stages of change correctly discriminated both decisional balance and self-efficacy, as well as replicated hypothesized relationships. Climate change doubt did not vary by stages; however, it may prove useful in future studies. Results support the validation of these measures and the application of the TTM to ST.

Acceptability and feasibility of a culturally tailored Internet-delivered intervention to promote blood donation in Blacks.

INTRODUCTION: A pilot test of a computer-tailored intervention designed to promote blood donation among Blacks was conducted. METHOD: Intervention content, based on the transtheoretical model, offered participants individually and culturally tailored information on blood donation with emphasis on need specific to race (e.g., sickle-cell disease). Black adults (N = 150) with a diversity of blood donation experience were recruited from a blood center and a survey recruitment website. Posttest assessment included a 14-item evaluation and transtheoretical model questions. RESULTS: Participants rated the program positively (81.3% to 98.7% of participants agreeing or strongly agreeing with evaluation items). For example, 98.7% of respondents reported that the program gave sound advice and that personal feedback was easily understood, and 87.3% felt the program was designed for people like themselves. Ninety-five percent of participants reported that they would recommend the program to others. There were no significant differences in ratings based on demographics. Qualitative responses support program acceptability. Furthermore, pre- and postprogram assessments indicated an increase in intention to donate, t(149) = 3.56, p = .001, d = .29. DISCUSSION: With acceptability and feasibility confirmed, the next steps are to test efficacy and cost-effectiveness for use to increase blood donation, particularly in priority populations.

Your Path to Transplant: a randomized controlled trial of a tailored computer education intervention to increase living donor kidney transplant.

BACKGROUND: Because of the deceased donor organ shortage, more kidney patients are considering whether to receive kidneys from family and friends, a process called living donor kidney transplantation (LDKT). Although Blacks and Hispanics are 3.4 and 1.5 times more likely, respectively, to develop end stage renal disease (ESRD) than Whites, they are less likely to receive LDKTs. To address this disparity, a new randomized controlled trial (RCT) will assess whether Black, Hispanic, and White transplant patients' knowledge, readiness to pursue LDKT, and receipt of LDKTs can be increased when they participate in the Your Path to Transplant (YPT) computer-tailored intervention. METHODS/DESIGN: Nine hundred Black, Hispanic, and White ESRD patients presenting for transplant evaluation at University of California, Los Angeles Kidney and Pancreas Transplant Program (UCLA-KPTP) will be randomly assigned to one of two education conditions, YPT or Usual Care Control Education (UC). As they undergo transplant evaluation, patients in the YPT condition will receive individually-tailored telephonic coaching sessions, feedback reports, video and print transplant education resources, and assistance with reducing any known socioeconomic barriers to LDKT. Patients receiving UC will only receive transplant education provided by UCLA-KPTP. Changes in transplant knowledge, readiness, pros and cons, and self-efficacy to pursue LDKT will be assessed prior to presenting at the transplant center (baseline), during transplant evaluation, and 4- and 8-months post-baseline, while completion of transplant evaluation and receipt of LDKTs will be assessed at 18-months post-baseline. The RCT will determine, compared to UC, whether Black, Hispanic, and White patients receiving YPT increase in their readiness to pursue LDKT and transplant knowledge, and become more likely to complete transplant medical evaluation and pursue LDKT. It will also examine how known patient, family, and healthcare system barriers to LDKT act alone and in combination with YPT to affect patients' transplant decision-making and behavior. Statistical analyses will be performed under an intent-to-treat approach. DISCUSSION: At the conclusion of the study, we will have assessed the effectiveness of an innovative and cost-effective YPT intervention that could be utilized to tailor LDKT discussion and education based on the needs of individual patients of different races in many healthcare settings. TRIAL REGISTRATION: ClinicalTrials.gov, number NCT02181114.

Measuring the processes of change for increasing blood donation in black adults.

BACKGROUND: Blacks have significantly lower blood donation rates than whites. Many views, experiences, and behaviors associated with blood donation are unique to black culture. Evidence suggests that culturally tailored health promotion programs help with increasing black blood donation. To be effective, tailored interventions should be based on valid and reliable measures. The Transtheoretical Model's (TTM) Processes of Change (POC) construct provides an assessment of participants' covert and overt activities and experiences in blood donation. This study describes development and validation of POC for increasing blood donation tailored to blacks. STUDY DESIGN AND METHODS: Cross-sectional measure development with online survey dissemination was used in 566 blacks in the Northeastern United States. Factor analytic structural modeling procedures were used to examine validity of the POC measure. Blood donation POC were examined in participants representing a range of blood donation history and intentions (nondonors, sometimes donors, regular donors) based on an established algorithm. RESULTS: Confirmatory analyses replicated the theoretically expected structure of POC scales which is a 10-factor, fully correlated best-fit model. Expected POC patterns by Stages of Change based on theoretical and empirical predictions were confirmed. The range of effect sizes for 10 POC were η(2) = 0.04 to 0.25, indicating that TTM POC are strong strategies in blood donation decision making for blacks and can be applied to interventions to increase blood donation for a minority population. CONCLUSION: POC measure was internally and externally valid in a sample of blacks. Interventions can utilize the POC measure to guide stage-matched interventions to encourage use of relevant experiential and behavioral strategies to increase blood donation.

Outcomes of cluster profiles within stages of change for sun protection behavior.

OBJECTIVE: Predictive and external validity was studied among cluster profiles for sun protection behavior within stages from Transtheoretical Model of behavior change using follow-up data. METHODS: Data from participants in a home-based expert system were analyzed. Longitudinal patterns of clusters on the precontemplation, contemplation, and preparation stages of change were assessed. Differences between clusters on membership in action/maintenance stages and scores on the Sun Protection Behavior Scale (SPBS) were measured at 12 and 24 months after intervention. RESULTS: Differences between clusters on stage progression and on scores from the SPBS were found at 12 and 24 months after intervention at all stages. DISCUSSION: Predictive and external validity of sun protection subtypes was established using sun protection variables after a stage-matched intervention. Results provide information to improve interventions for sun protection.

Measuring Motivation for COVID-19 Vaccination: An Application of the Transtheoretical Model.

PURPOSE: In the United States (US), individuals vary widely in their readiness to get vaccinated for COVID-19. The present study developed measures based on the transtheoretical model (TTM) to better understand readiness, decisional balance (DCBL; pros and cons), self-efficacy (SE), as well as other motivators for change such as myths and barriers for COVID-19 vaccination. DESIGN: Cross-sectional measurement development. SETTING: Online survey. SAMPLE: 528 US adults ages 18-75. MEASURES: Demographics, stage of change (SOC), DCBL, SE, myths, and barriers. ANALYSIS: The sample was randomly split into halves for exploratory factor analysis using principal components analysis (EFA/PCA), followed by confirmatory factor analyses (CFA) to test measurement models. Correlation matrices were assessed and multivariate analyses examined relationships between constructs and sub-constructs. RESULTS: For DCBL, EFA/PCA revealed three correlated factors (one pros, two cons) (n1 = 8, α = .97; n2 = 5, α = .93; n3 = 4, α = .84). For SE, two correlated factors were revealed (n1 = 12, α = .96; n2 = 3, α = .89). Single-factor solutions for Myths (n = 13, α = .94) and Barriers (n = 6, α = .82) were revealed. CFA confirmed models from EFAs/PCAs. Follow-up analyses of variance aligned with past theoretical predictions of the relationships between SOC, pros, cons, and SE, and the predicted relationships with myths and barriers. CONCLUSION: This study produced reliable and valid measures of TTM constructs, myths, and barriers to understand motivation to receive COVID-19 vaccination that can be used in future research.

Treated individuals who progress to action or maintenance for one behavior are more likely to make similar progress on another behavior: coaction results of a pooled data analysis of three trials.

OBJECTIVE: This study compared, in treatment and control groups, the phenomena of coaction, which is the probability that taking effective action on one behavior is related to taking effective action on a second behavior. METHODS: Pooled data from three randomized trials of Transtheoretical Model (TTM) tailored interventions (n=9461), completed in the U.S. in 1999, were analyzed to assess coaction in three behavior pairs (diet and sun protection, diet and smoking, and sun protection and smoking). Odds ratios (ORs) compared the likelihood of taking action on a second behavior compared to taking action on only one behavior. RESULTS: Across behavior pairs, at 12 and 24 months, the ORs for the treatment group were greater on an absolute basis than for the control group, with two being significant. The combined ORs at 12 and 24 months, respectively, were 1.63 and 1.85 for treatment and 1.20 and 1.10 for control. CONCLUSIONS: The results of this study with addictive, energy balance and appearance-related behaviors were consistent with results found in three studies applying TTM tailoring to energy balance behaviors. Across studies, there was more coaction within the treatment group. Future research should identify predictors of coaction in more multiple behavior change interventions.

Cluster subtypes within the precontemplation stage of change for sun protection behavior.

The aim of this study is to identify replicable cluster subtypes within the precontemplation stage of change for sun protection. Secondary data analysis of baseline data from a sample of participants in a home-based expert system intervention was performed. Three random samples were selected from participants in the precontemplation stage (N = 570). Cluster analyses were performed using the scales of pros, cons, and self-efficacy. Interpretability of pattern, pseudo F-test, and dendograms were used to determine the number of clusters. A four-cluster solution replicated across subsamples. Significant differences between clusters on the nine processes of change and on behavioral measures were found. Cluster solutions were robust, interpretable and with good initial external validity. They replicated patterns found for other behaviors, demonstrating long-term predictability and providing basis for tailored interventions.

Effect of Computer-Tailored Print Feedback, Motivational Interviewing, and Motivational Enhancement Therapy on Engagement in Advance Care Planning: A Randomized Clinical Trial.

Importance: There is a tension between clinician-led approaches to engagement in advance care planning (ACP), which are effective but resource-intensive, and self-administered tools, which are more easily disseminated but rely on ability and willingness to complete. Objective: To examine the efficacy of computer-tailored print feedback (CTPF), motivational interviewing (MI), and motivational enhancement therapy (MET) on completion of a set of ACP activities, each as compared with usual care. Design, Setting, and Participants: This randomized clinical trial was conducted from October 2017 to December 2020 via telephone contact with primary care patients at a single VA facility; 483 veterans aged 55 years or older were randomly selected from a list of patients with a primary care visit in the prior 12 months, with oversampling of women and people from minoritized racial and ethnic groups. Statistical analysis was performed from January to June 2022. Interventions: Mailed CTPF generated in response to a brief telephone assessment of readiness to engage in and attitudes toward ACP; MI, an interview exploring ambivalence to change and developing a change plan; and MET, MI plus print feedback, delivered by telephone at baseline, 2, and 4 months. Main Outcome and Measures: Self-reported completion of 4 ACP activities: communicating about views on quality vs quantity of life, assignment of a health care agent, completion of a living will, and submitting documents for inclusion in the electronic health record at 6 months. Results: The study included 483 persons, mean (SD) age 68.3 (8.0) years, 18.2% women and 31.1% who were people from minoritized racial and ethnic groups. Adjusting for age, education, race, gender, and baseline stage of change for each ACP, predicted probabilities for completing the ACP activities were: usual care 5.7% (95% CI, 2.8%-11.1%) for usual care, 17.7% (95% CI, 11.8%-25.9%; P = .003) for MET, 15.8% (95% CI, 10.2%-23.6%; P = .01) for MI, P = .01, and 10.0% (95% CI, 5.9%-16.7%; P = .18) for CTPF. Conclusions and Relevance: This randomized clinical trial found that a series of 3 MI and MET counseling sessions significantly increased the proportion of middle-aged and older veterans completing a set of ACP activities, while print feedback did not. These findings suggest the importance of clinical interaction for ACP engagement. Trial Registration: ClinicalTrials.gov Identifier: NCT03103828.

Applying the Transtheoretical Model to Stuttering Management Among Adolescents: Part I. Scale Development.

Purpose This article is the first in a two-part series on the application of the Transtheoretical Model to stuttering management among adolescents. In this article, we describe the process of developing measures to assess stage of change (SOC) by defining behaviors of stuttering management, as well as the two primary cognitive constructs that underlie one's readiness to make behavioral change: decisional balance (DB) and situational self-efficacy (SSE). This work hinges on the ability to develop an operational definition of what it means to successfully manage or do something positive about one's stuttering. Method We used an iterative process to develop the three scales. Through qualitative analysis of key informant interview and focus group transcripts with 24 adolescents who stutter and 26 clinicians specializing in stuttering, we developed stuttering-specific SOC, DB, and SSE scales. The drafted scales were cognitively tested with nine adolescents who stutter. Results Thematic analysis yielded a three-part definition of successful stuttering management that formed the basis for the SOC scale: (a) learning and using strategies to modify speech or stuttering, (b) changing negative thoughts and attitudes regarding stuttering, and (c) talking without avoiding sounds, words, or situations. Results from this analysis support a broader view of successful stuttering management; that is, it is likely that doing so requires more than just behavior change, which has long been considered the main objective of stuttering treatment. Additional analyses yielded pros and cons of managing stuttering (62 items for the DB scale) and situations in which it is difficult to manage stuttering (39 items for the SSE scale). Conclusions Qualitative analyses provided a three-part definition of "stuttering management" and a comprehensive pool of items that would allow measurement of DB and SSE that underlie readiness to manage stuttering among adolescents. In the companion article in this two-part series, we describe the next step in scale development: exploratory scale validation of the drafted SOC, DB, and SSE scales.

Applying the Transtheoretical Model to Stuttering Management Among Adolescents: Part II. Exploratory Scale Validation.

Purpose This article is the second in a two-part series on the application of the Transtheoretical Model to stuttering management among adolescents. The purpose of this article was to apply and explore the validity of newly developed Transtheoretical measures for adolescents who stutter. Method The online survey was completed by a national sample of 173 adolescents who stutter between the ages of 13 and 21 years. The multipart survey included a Stage of Change scale, Decisional Balance scale, and Situational Self-Efficacy scale. Participants also completed the Overall Assessment of the Speaker's Experience of Stuttering (OASES), either the teenage or adult version depending on the participant's age, so preliminary construct validity of the new scales could be examined. Exploratory factor analyses were conducted to determine model fit and reduce the scales to the most meaningful items. External validity of the three-part survey was examined by comparing OASES scores across stage of change as well as evaluating the functional relations between the three scales. Results Adolescents' readiness to manage stuttering could be clearly described with five discrete stages, although most of the respondents reported being in the Maintenance stage. The pros of managing stuttering reliably predicted stage placement. Internal consistency of the scales ranged from good to excellent. OASES scores differed across stages of readiness in complex but predictable ways. Conclusions These findings suggest that the Transtheoretical Model fits the target behaviors involved stuttering management among adolescents. Further examination of the application of the model to validate a stage-based framework for change among individuals who stutter is warranted.

Results of a multi-media multiple behavior obesity prevention program for adolescents.

BACKGROUND: This study reports on effectiveness trial outcomes of Health in Motion, a computer tailored multiple behavior intervention for adolescents. METHODS: Using school as level of assignment, students (n=1800) from eight high schools in four states (RI, TN, MA, and NY) were stratified and randomly assigned to no treatment or a multi-media intervention for physical activity, fruit and vegetable consumption, and limited TV viewing between 2006 and 2007. RESULTS: Intervention effects on continuous outcomes, on movement to action and maintenance stages, and on stability within action and maintenance stages were evaluated using random effects modeling. Effects were most pronounced for fruit and vegetable consumption and for total risks across all time points and for each behavior immediately post intervention. Co-variation of behavior change occurred within the treatment group, where individuals progressing to action or maintenance for one behavior were 1.4-4.2 times more likely to make similar progress on another behavior. CONCLUSION: Health in Motion is an innovative, multiple behavior obesity prevention intervention relevant for all adolescents that relies solely on interactive technology to deliver tailored feedback. The outcomes of the effectiveness trial demonstrate both an ability to initiate behavior change across multiple energy balance behaviors simultaneously and feasibility for ease of dissemination.

Cross-validation of transtheoretical model smoking cessation measures in Chicago WIHS women smokers with and at risk for HIV.

People with and at risk for HIV have high rates of smoking, increasing their morbidity and mortality. Effective cessation interventions are needed for this group. Transtheoretical model (TTM)-tailored interventions have demonstrated efficacy, but measures need cross-validation in this population. TTM cessation measures were evaluated in women smokers with and at risk for HIV (N = 111) from Chicago Women's Interagency HIV Study (WIHS). Confirmatory factor analyses evaluated measurement models. MANOVAs examined relationships between constructs and stage subgroups. For decisional balance, the two-factor uncorrelated model was best (χ2(20) = 13.96; comparative fit index [CFI], 1.0; root mean square error of approximation [RMSEA] = .00), with good (pros α = .78) and fair (cons α = .55) four-item alphas. The one-factor temptations model (α = .90) showed reasonable fit (χ2(18) = 80.22; CFI = .89; RMSEA = .177). Processes of change subscales had fair to good two-item alphas (α = .49-.77) and fit a 10-factor fully correlated model (χ2(125) = 222.72; CFI = .88; RMSEA = .084). MANOVAs by stage of change replicated expected patterns for the pros, overall temptations, and two process subscales with medium-sized effects (η2 = .06-.18). Contrary to expectations, no differences by stage were found for cons or temptation negative affect subscales. The structures of these TTM measures replicated with good internal and external validity, except for the cons, which needs refinement. Negative affect temptations was structurally sound, but did not vary by stage group potentially reflecting this sample's moderate depression levels and/or their reliance on smoking to deal with negative affect. Results support the use of most TTM measures in research and tailored interventions to increase smoking cessation among women smokers with and at risk for HIV and highlight the importance of managing negative affect in cessation materials targeting this group.

Development and Validation of a Socioeconomic Kidney Transplant Derailers Index.

Socioeconomic barriers can prevent successful kidney transplant (KT) but are difficult to measure efficiently in clinical settings. We created and validated an individual-level, single score Kidney Transplant Derailers Index (KTDI) and assessed its association with waitlisting and living donor KT (LDKT) rates. METHODS: The dataset included 733 patients presenting for KT evaluation in a transplant center in California. Exploratory factor analysis was used to identify socioeconomic barriers to KT (derailers) to include in the index. Potential KT derailers included health insurance, employment, financial insecurity, educational attainment, perception of neighborhood safety, access to a vehicle, having a washer/dryer, and quality of social support. Validity was tested with associations between KTDI scores and the following: (1) the Area Deprivation Index (ADI) and (2) time to KT waitlisting and LDKT. RESULTS: Nine derailers were retained, omitting only social support level from the original set. The KTDI was scored by summing the number of derailers endorsed (mean: 3.0; range: 0-9). Black patients had higher estimated KTDI scores than other patient groups (versus White patients, 3.8 versus 2.1; P < 0.001, effect size = 0.81). In addition, the KTDI was associated with the ADI (γ = 0.70, SE = 0.07; P < 0.001). Finally, in comparison to the lower tertile, patients in the upper and middle KTDI tertiles had lower hazard of waitlisting (upper tertile hazard ratio [HR]: 0.34, 95% confidence interval [CI]: 0.25-0.45; middle tertile HR: 0.54, 95% CI: 0.40-0.72) and receiving an LDKT (upper tertile HR: 0.15, 95% CI: 0.08-0.30; middle tertile HR: 0.35, 95% CI: 0.20-0.62). These associations remained significant when adjusting for the ADI and other patient characteristics. CONCLUSIONS: The KTDI is a valid indicator of socioeconomic barriers to KT for individual patients that can be used to identify patients at risk for not receiving a KT.