The value of partnerships in state obesity prevention and control programs.

State health departments funded by the Centers for Disease Control and Prevention's Nutrition, Physical Activity, and Obesity Program collaborate with multiple partners to develop and implement comprehensive obesity prevention and control programs. A mixed-methods evaluation of 28 state programs over a 5-year period assessed states' progress on program requirements, including developing statewide partnerships and coordinating with partners to support obesity prevention and control efforts. States with greater partnership involvement leveraged more funding support for their programs, passed more obesity-related policies, and were more likely to implement obesity interventions in multiple settings. Case studies provided guidance for establishing and maintaining strong partnerships. Findings from this study offer emerging evidence to support assumptions about the centrality of partnerships to states' success in obesity program development and implementation and related health promotion activities.

Agents of change: how do complementary and alternative medicine providers play a role in health behavior change?

BACKGROUND: Recent investigations indicate that complementary and alternative medicine (CAM) use may be conducive to health behavior change. OBJECTIVE: The goal of this study was to investigate how this change occurs. METHODS: Using Social Cognitive Theory and Self-determination Theory as guiding frameworks, we surveyed a convenience sample of 216 CAM consumers abouttheir CAM therapy and iors and conducted focus groups with 36 CAM consumers. RESULTS: Consumers reported encouragement from providers and improved energy resulting from treatments as reasons for making health behavior changes. Multivariate analysis showed that increased odds of self-reported dietary change were significantly associated with increasing body awareness as a result of therapy, endorsing the statement that sustained improvement for their health conditions required self-care, using an acupuncturist, and being 44 years or younger. Comparable results were found for exercise change, except using an acupuncturist was a significant negative predictor and age was not significant. Focus group findings echoed these themes. CONCLUSION: This initial investigation into how CAM providers may play a role in health behavior change suggests that provider support, increased responsibility for one's health, and the CAM treatments themselves contribute to behavior change, although additional research in this area is warranted.

Communication message strategies for increasing knowledge about prostate cancer screening.

BACKGROUND: This community-based intervention study examined the effects of 2 different message strategies for presenting information about the prostate specific antigen (PSA) test. METHODS: A quasi-experimental longitudinal design with 2 intervention and 1 control group. RESULTS: Knowledge increased significantly among participants who received either version of the intervention message and remained elevated at 12 months. Presenting information in the context of other men's health issues was associated with greater increases in knowledge relative to PSA only. CONCLUSIONS: Community-based interventions can increase knowledge about prostate cancer screening. Clinicians need to take careful account of what their patients understand and correct misperceptions.

Promoting fruit and vegetable intake through messages tailored to individual differences in regulatory focus.

BACKGROUND: Researchers must identify strategies to optimize the persuasiveness of messages used in public education campaigns encouraging fruit and vegetable (FV) intake. PURPOSE: This study examined whether tailoring messages to individuals' regulatory focus (RF), the tendency to be motivated by promotion versus prevention goals, increased the persuasiveness of messages encouraging greater FV intake. METHOD: Participants (n = 518) completed an assessment of their RF and were randomly assigned to receive either prevention- or promotion-oriented messages. Messages were mailed 1 week, 2 months, and 3 months after the baseline interview. Follow-up assessments were conducted 1 and 4 months after the baseline assessment. RESULTS: Regression analyses revealed that at Month 4, the messages were somewhat more efficacious when congruent with participants' RF. CONCLUSION: RF may be a promising target for developing tailored messages promoting increased FV intake, and particularly for encouraging individuals to meet FV guidelines.

Development and validation of an instrument to measure resources and support for chronic illness self-management: a model using diabetes.

PURPOSE: Few comprehensive and practical instruments exist to measure the receipt of self-management support for chronic illness. An instrument was developed to measure resources and support for self-management (RSSM) for the survey component of the evaluation of the Robert Wood Johnson Foundation's Diabetes Initiative. It includes items to measure an ecological range of RSSM. This article describes the development and validation of the instrument, focusing on individuals' reported access to RSSM from providers and from nonclinical, social, and community sources. METHODS: Cross-sectional analyses of the second wave of a survey of participants in the Diabetes Initiative (68% response rate, n = 957) were used. RESULTS: Confirmatory factor analyses supported grouping the 17 items into 5 subscales, measuring key aspects of RSSM: individualized assessment, collaborative goal setting, enhancing skills, ongoing follow-up and support, and community resources (comparative fit index = 0.97, Tucker-Lewis fit index = 0.99, and root means square error of approximation = 0.06). The overall scale and 5 subscales were internally consistent (Cronbach alpha >or= .70) and were significantly, positively related to diabetes self-management behaviors, supporting their construct validity. CONCLUSIONS: This instrument shows promise for measuring RSSM. Although it was developed for diabetes programs, its ecological orientation and link to the broad framework of chronic care suggest broader application.

A new evaluation tool to obtain practice-based evidence of worksite health promotion programs.

INTRODUCTION: The Centers for Disease Control and Prevention developed the Swift Worksite Assessment and Translation (SWAT) evaluation method to identify promising practices in worksite health promotion programs. The new method complements research studies and evaluation studies of evidence-based practices that promote healthy weight in working adults. METHODS: We used nationally recognized program evaluation standards of utility, feasibility, accuracy, and propriety as the foundation for our 5-step method: 1) site identification and selection, 2) site visit, 3) post-visit evaluation of promising practices, 4) evaluation capacity building, and 5) translation and dissemination. An independent, outside evaluation team conducted process and summative evaluations of SWAT to determine its efficacy in providing accurate, useful information and its compliance with evaluation standards. RESULTS: The SWAT evaluation approach is feasible in small and medium-sized workplace settings. The independent evaluation team judged SWAT favorably as an evaluation method, noting among its strengths its systematic and detailed procedures and service orientation. Experts in worksite health promotion evaluation concluded that the data obtained by using this evaluation method were sufficient to allow them to make judgments about promising practices. CONCLUSION: SWAT is a useful, business-friendly approach to systematic, yet rapid, evaluation that comports with program evaluation standards. The method provides a new tool to obtain practice-based evidence of worksite health promotion programs that help prevent obesity and, more broadly, may advance public health goals for chronic disease prevention and health promotion.

Promising practices in promotion of healthy weight at small and medium-sized US worksites.

INTRODUCTION: We developed a new evaluation method to identify promising practices for promoting healthy weight among employees at small and medium-sized worksites. METHODS: We used a structured rating and selection process to select 9 worksites with approximately 100 to 3,000 employees from a pool of worksites with health promotion programs reputed to be exemplary. A site visit over 2 sequential half-days at each site included interviews with senior management, program staff, vendors, and wellness committees; observation guided by a written environmental assessment; and structured review of program data on health outcomes of wellness program participants. The team corroborated findings from interviews, observations, and reviews of aggregate data on health outcomes of participants. Using the site visit reports, the project team and a separate panel of experts identified worksite health promotion practices that were promising, innovative, feasible to implement in a variety of settings, sustainable, and relevant for public health. RESULTS: Innovative practices included peer coaching, wellness screening coupled with motivational interviewing and follow-up, free access to fitness facilities, and incentives such as days of paid leave for participation in wellness programs. Introduction of incentives was associated with higher participation rates. To build the business case for their programs, staff at several worksites used aggregate data on decreases in high blood pressure, serum cholesterol concentrations, and body weight in longitudinal samples of program participants. CONCLUSION: The evaluation method identified promising practices implemented at small and medium-sized worksites to promote healthy weight and related favorable health outcomes.

Matching health messages to monitor-blunter coping styles to motivate screening mammography.

This study examined whether providing messages matched to women's monitor-blunter coping styles is effective in encouraging mammography utilization. Female callers to a cancer information hotline were assessed at the end of their regular telephone call and classified as monitors or blunters. A randomly assigned message promoting mammography utilization, tailored for monitors or blunters, was delivered on the telephone, and a similarly tailored brochure and refrigerator magnet were mailed to participants immediately after their call. Women were telephoned 6 and 12 months later to determine whether they had obtained a mammogram. Messages matched to a woman's monitor-blunter coping style encouraged mammography after 6 months more effectively than mismatched messages and were significantly more effective for blunters but not for monitors.

Casting health messages in terms of responsibility for dietary change: increasing fruit and vegetable consumption.

OBJECTIVE: To compare the effectiveness of messages emphasizing the importance of either personal or social responsibility for dietary behavior change in increasing fruit and vegetable intake. DESIGN/SETTING: Randomly assigned individually or socially oriented messages were delivered at baseline, 1 week, and 2 and 3 months later. Telephone surveys were conducted at baseline and 1 and 4 months later. PARTICIPANTS: 528 callers to a cancer information hotline who were not meeting the "5 A Day" dietary recommendation. INTERVENTIONS: A brief telephone-delivered message and 3 mailings of pamphlets and promotional items encouraging fruit and vegetable intake that emphasized either personal or social responsibility. MAIN OUTCOME MEASURES: Fruit and vegetable intake 1 and 4 months post baseline. ANALYSIS: Chi-square, t tests, and analyses of variance and covariance. RESULTS: Both types of messages increased intake substantially (P =.01). To some extent, the social responsibility message continued to motivate increased intake over time compared with the personal responsibility message. CONCLUSIONS AND IMPLICATIONS: These minimal interventions had a substantial impact on fruit and vegetable intake. Health messages might be more effective over the longer term if they are designed to emphasize the importance of social responsibility, although further study is needed to confirm the robustness of these findings.

Measuring patient-centered communication in cancer care: a literature review and the development of a systematic approach.

Patient-centered communication (PCC) is a critical element of patient-centered care, which the Institute of Medicine (Committee on Quality of Health Care in America, 2001) promulgates as essential to improving healthcare delivery. Consequently, the US National Cancer Institute's Strategic Plan for Leading the Nation (2006) calls for assessing the delivery of PCC in cancer care. However, no comprehensive measure of PCC exists, and stakeholders continue to embrace different conceptualizations and assumptions about how to measure it. Our approach was grounded in the PCC conceptual framework presented in a recent US National Cancer Institute monograph (Epstein & Street, 2007). In this study, we developed a comprehensive inventory of domains and subdomains for PCC by reviewing relevant literature and theories, interviewing a limited number of cancer patients, and consulting experts. The resulting measurement domains are organized under the six core functions specified in the PCC conceptual framework: exchanging information, fostering healing relationships, recognizing and responding to emotions, managing uncertainty, making decisions, and enabling patient self-management. These domains represent a promising platform for operationalizing the complicated PCC construct. Although this study focused specifically on cancer care, the PCC measurements are relevant to other clinical contexts and illnesses, given that patient-centered care is a goal across all healthcare. Finally, we discuss considerations for developing PCC measures for research, quality assessment, and surveillance purposes. United States Department of Health and Human Services, National Institutes of Health, National Cancer Institute (2006). The NCI Strategic Plan for Leading the Nation: To Eliminate the Suffering and Death Due to Cancer. NIH Publication No. 06-5773.

Translating medical evidence to promote informed health care decisions.

OBJECTIVE: To examine the effects of a community-based intervention on decisions about prostate-specific antigen (PSA) screening using multiple measures of informed decision making (IDM). DATA SOURCES/STUDY SETTING: Nonequivalent control group time series design collecting primary data in late 2004 and 2005. STUDY DESIGN: We developed a multimodal intervention designed to convey the medical uncertainty about the benefits of PSA screening and early treatment and the limited predictive ability of both the PSA test and pathological specimens collected from prostate biopsy. We examined (1) patients' recognition that there is a decision to be made about PSA screening, (2) prostate cancer knowledge levels, (3) their preferred and actual levels of participation in decision making about screening at three points in time, and (4) screening decision. DATA COLLECTION: Baseline data collection occurred in community-based organizations. These organizations served as recruiting sources and as sites for the intervention. We collected follow-up data by mail with telephone reminders. PRINCIPAL FINDINGS: Our intervention was associated with greater recognition of the PSA test as a decision to be made, levels of knowledge, both preferred and actual levels of involvement in decision making, but did not have an impact on the screening decision. CONCLUSIONS: Community-based interventions can influence key measures of IDM about PSA screening.

An evaluation of health communication materials for individuals with disabilities developed by three state disability and health programs.

BACKGROUND: Health communication increasingly has been recognized as an important part of public health practice that can help raise awareness of potential health risks, influence attitudes and beliefs, and motivate individuals to change unhealthy behaviors. Yet, few health communication messages exist that target people with disabilities. An evaluation was conducted to assess the relevance and usefulness of health communication materials developed by or disseminated in, or both, three state disability and health programs. METHODS: Health care providers and people with a variety of physical and sensory disabilities participated in the evaluation. Qualitative and quantitative data were collected in each of the three states using key informant interviews, focus groups, and a Web-based provider survey. RESULTS: State program staff reported that health communication strategies and messages should be developed to improve access and remove barriers to health care, provide access to facilities, empower consumers, and educate health care providers about the needs of people with disabilities. Several of these needs are consistent with the needs identified by consumers in the focus groups. Consumers indicated that improvements to the overall content and design of the state-developed health communication materials are needed, yet health care and human service providers who participated in the Web-based survey were generally satisfied with the materials. Nearly all providers reported being aware of the materials; however, consumers were not familiar with the state-developed materials reviewed by the focus groups. CONCLUSIONS: Improvements in the content and dissemination of health promotion materials designed by states are indicated. Implications for public health practice, including recommendations for improving future health communication materials, are addressed in this article.

The association between funding for statewide programs and enactment of obesity legislation.

OBJECTIVE: As part of a national effort to prevent and control obesity, the Centers for Disease Control and Prevention's (CDC's) Nutrition and Physical Activity Program to Prevent Obesity and Other Chronic Diseases (NPAO) provides funding to states to improve access to healthful food and increase opportunities for physical activity. The CDC also provides funding to states to build Coordinated School Health (CSH) programs across agencies and within schools to help reduce chronic disease risk factors. This paper investigates the possible role of these programs in state policy change. METHODS: Descriptive study of state legislation targeting obesity prevention passed in 2005. Units of analysis were 135 pieces of obesity-related state legislation identified within 4 legislative databases. Legislation was coded into programmatic setting and obesity-prevention strategy categories. RESULTS: On average, states receiving NPAO or CSH program funding passed twice as many bills as states not yet funded. CONCLUSIONS AND IMPLICATIONS: The statewide obesity prevention and school health programs may have contributed to states enacting more obesity-related legislation. Further research into the process by which state programs influence the enactment and effective implementation of policies could help build the evidence base for policy changes that help prevent obesity.

Behind Closed Doors: What Happens when Patients and Providers Talk about Prostate-Specific Antigen Screening?: Survey of the Effects of a Community-Based Intervention.

BACKGROUND: : Prostate-specific antigen (PSA) screening is controversial because of uncertainty about whether it reduces mortality and whether the potential benefits outweigh the harms. Given these uncertainties, many medical associations recommend using an informed decision-making (IDM) process for making decisions about PSA screening, so that men can make well informed decisions that reflect their values and preferences. OBJECTIVE: : The aim of this paper was to describe the communication exchange between men and their providers regarding PSA screening and the outcomes associated with having a discussion about screening from the patient perspective. METHODS: : We evaluated survey results obtained at baseline and approximately 12 months post-intervention. Baseline data collection took place in community-based organizations, and follow-up data were collected by mail. Men between 40 and 80 years of age who had not been diagnosed with prostate cancer were eligible for the study. We implemented a multicomponent, community-based intervention designed to help men make informed decisions about PSA screening. Primary outcome measures included characteristics of patient-provider discussions, screening behavior, feeling informed and satisfied, and patients' preferred and actual levels of involvement in screening decisions and concordance between the two. RESULTS: : Overall, 59% of men (220 of 373) had a discussion with a healthcare professional about the PSA screening test. Older men (those aged ≥50 years), Black men, and those who were married were more likely to talk to a provider. When a discussion did occur, two out of three men said that the discussion affected their decision making, and one-quarter changed their screening choice as a result. According to patients, there was apparent variation regarding the extent to which providers recommended the PSA test: 68% of providers recommended it and 3% did not recommend it. One in ten men said that the provider ordered the test without making a recommendation, while 15% of men said that providers did not make a recommendation and wanted the patient to decide.We found that the discussion between the patient and the provider about PSA screening was significantly associated with a greater probability of feeling informed and higher levels of satisfaction with the decision that was made. Most men preferred to be and were involved in the PSA screening decision collaboratively with their providers. When preferred and actual levels of involvement were concordant (i.e. men participated at their preferred level) and when men asked questions, men reported feeling more informed and satisfied about the screening decision. CONCLUSION: : Ongoing education about the US Preventive Services Task Force (USPSTF) recommendation with respect to PSA screening should occur not only at the patient level but also at the provider level. More widespread adoption of the IDM process, which inherently involves building a patient's self-efficacy and skills needed to engage in it, is likely to take time.

Tailoring messages to individual differences in monitoring-blunting styles to increase fruit and vegetable intake.

OBJECTIVE: To examine whether messages matched to individuals' monitoring-blunting coping styles (MBCS) are more effective in increasing fruit and vegetable intake than mismatched messages. MBCS refers to the tendency to either attend to and amplify, or distract oneself from and minimize threatening information. DESIGN/SETTING: Randomly assigned messages were tailored to resonate with either monitors or blunters and delivered at baseline, 1 week, 2 months, and 3 months later. Surveys were conducted at baseline and 2 and 4 months later. PARTICIPANTS: 531 callers to a cancer information hotline who did not meet the 5 A Day guideline. INTERVENTION: A brief telephone-delivered message and 3 mailings of booklets and promotional items encouraging fruit and vegetable intake, tailored for either monitors or blunters. MAIN OUTCOME MEASURE: Fruit and vegetable intake 2 and 4 months post-baseline. ANALYSIS: Hierarchical regression modeling. RESULTS: Messages matched to MBCS were more effective than mismatched messages, particularly for the monitor message, in increasing intake at 2 months but not at 4 months. CONCLUSIONS AND IMPLICATIONS: These minimal interventions influenced fruit and vegetable intake. MBCS may be a promising target for developing tailored messages aimed at increasing intake, although additional research is needed to verify the robustness of these findings.

Bridging the digital divide by increasing computer and cancer literacy: community technology centers for head-start parents and families.

This article describes the establishment of two community technology centers affiliated with Head Start early childhood education programs focused especially on Latino and African American parents of children enrolled in Head Start. A 6-hour course concerned with computer and cancer literacy was presented to 120 parents and other community residents who earned a free, refurbished, Internet-ready computer after completing the program. Focus groups provided the basis for designing the structure and content of the course and modifying it during the project period. An outcomes-based assessment comparing program participants with 70 nonparticipants at baseline, immediately after the course ended, and 3 months later suggested that the program increased knowledge about computers and their use, knowledge about cancer and its prevention, and computer use including health information-seeking via the Internet. The creation of community computer technology centers requires the availability of secure space, capacity of a community partner to oversee project implementation, and resources of this partner to ensure sustainability beyond core funding.

Health information styles among participants in a prostate cancer screening informed decision-making intervention.

The purpose of this study was to assess the usefulness of a health information styles segmentation strategy in understanding audience subgroups. We examined the health information styles of men participating in a prostate cancer screening informed decision-making (IDM) intervention and assessed intervention effects on men with distinct health information styles. We classified participants into three health information style groups based on their independence in health decision making (independent versus doctor dependent) and engagement in health enhancement (active versus passive): independent active (IA), doctor-dependent active (DDA) and passive. We developed profiles of men in these groups: IAs tended to be white and more highly educated and to have greater baseline prostate cancer knowledge; DDAs were older, less healthy and more likely to have visited a doctor in the past year and passives tended to be younger, not to have had a recent prostate-specific antigen test and to have lower self-efficacy related to communication with doctors and less positive interactions with doctors. All groups significantly increased their prostate cancer knowledge after the intervention, but passives exhibited the greatest increase in knowledge at a 6-month follow-up. The health information styles segmentation strategy used in this study offers a viable framework for segmenting audiences.

Validation of a scale for the assessment of food cravings among smokers.

Weight gain associated with smoking cessation impedes attempts to quit smoking and may lead to obesity. One factor that might contribute to weight gain is cravings for sweet or rich foods. To date, no reliable measure exists for evaluating these cravings. The purpose of the current study was to validate an assessment of craving for sweet or rich foods for use among smokers. With a sample of 385 smokers enrolled in a clinical trial for smoking cessation, the study examined the factor structure, internal consistency, and convergent and predictive validity of the Questionnaire on Craving for Sweet or Rich Foods (QCSRF). A two-factor model best represented the data. Factor 1 contained six items assessing perceptions about the ability of sweet or rich foods to relieve negative affect and about self-control over eating. Factor 2 contained three items assessing the intensity of cravings. Both factors demonstrated high internal consistency and good convergent and predictive validity. These results suggest the QCSRF is a reliable and valid measure for examining cravings for sweet or rich foods among smokers.

Need for cognition and message complexity in motivating fruit and vegetable intake among callers to the cancer information service.

This field experiment examined the impact of an individual's need for cognition (NFC; the tendency to enjoy thinking deeply about issues), complex versus simple messages, and the interaction of NFC and message type on encouraging fruit and vegetable consumption. Callers to the Cancer Information Service of the National Cancer Institute (N=517) were asked to participate in the experiment at the end of their call. Individual NFC was assessed, and participants were assigned randomly to receive a telephone message promoting fruit and vegetable consumption that was either complex and multifaceted or simple and straightforward. Similarly constructed brochures were mailed immediately following the call, and additional brochures were mailed 2 and 3 months later. Although NFC did not predict intake, complex messages were more effective than simple messages in motivating fruit and vegetable consumption 1 and 4 months later.

Matching health messages to information-processing styles: need for cognition and mammography utilization.

The use of tailored health communications has become a favored technique for persuading individuals to engage in health behaviors, such as screening mammography. This experiment examined the impact of tailoring persuasive health communications to one aspect of individuals' information-processing styles, that of the need for cognition (NFC), the enjoyment of thinking deeply about issues. To determine whether messages matched to an individual's NFC are more influential than mismatched messages, 602 women who called the Cancer Information Service (CIS) of the National Cancer Institute were asked to participate in an experiment at the end of their service call. They were assigned randomly to receive 1 of 2 phone messages promoting mammography use and a similarly tailored pamphlet 1 month later. Messages matched to an individual's NFC were better at motivating mammography 6 months later among high-NFC women. After controlling for prior mammography utilization, age, worry, intentions, perceived norms, suggestions to get a mammogram, and marital status, the interaction between participant NFC and message type also approached statistical significance. The differential influence of these brief, tailored communications diminished after 12 months, however.