Physical Activity Intervention Adaptation: Recommendations from Rural American Indian Older Adults.

Preventive interventions are critical to improving health equity among American Indian (AI) populations, yet interventions that promote physical activity (PA) among AI populations are scarce. This research addresses the research-to-practice gap by informing the adaption and implementation process of evidence-based interventions (EBIs) among rural AI older adults. We used a community-based approach and an Indigenous-focused adaptation theoretical framework. Qualitative, semi-structured interviews elicited detailed information on preferences for PA intervention among rural AI older adults. We applied a collaborative directed content analysis strategy, and established trustworthiness and relevance using an inter-rater reliability process and member checking. We conducted 21 interviews, all participants identified as AI, the mean age was 66 years (SD = 7.6), and 57% were female. Themes characterized contextual and cultural intervention considerations for adapting and implementing evidence-based PA interventions in rural AI older adults. Key findings included an emphasis on social and community interaction, strategies for targeted engagement, preference for group format, pairing PA sessions with shared meals, and inclusiveness in the PA intervention across ability levels and age groups. This study identified opportunities for adaptation of PA-focused EBIs among rural AI older adults. Findings can be applied to support the adaptation and implementation of effective and relevant PA-focused preventive interventions among this population which is at high risk for chronic disease and health disparities.

Recruiting unmotivated smokers into a smoking induction trial.

Little is known about effective methods to recruit unmotivated smokers into cessation induction trials, the reasons unmotivated smokers agree to participate, and the impact of those reasons on study outcomes. A mixed-method approach was used to examine recruitment data from a randomized controlled cessation induction trial that enrolled 255 adult smokers with low motivation to quit. Over 15 months, 33% of smokers who inquired about the study were enrolled. Common recruitment methods included word-of-mouth, print advertisements and clinic referrals. Frequently mentioned reasons for participating included to: gain financial incentives (44.7%), learn about research or help others quit (43%), learn about smoking and risks (40%) and help with future quits (i.e. Quit Assistance, 23.9%). Separate regression models predicting study outcomes at 26 weeks indicated that smokers who said they participated for Quit Assistance reported higher motivation to quit (B 1.26) and were more likely to have made a quit attempt (OR 2.03) compared to those not mentioning this reason, when baseline characteristics were controlled. Understanding reasons for unmotivated smokers' interest in treatment can help practitioners and researchers design effective strategies to engage this population.

Relationship of Autonomy Social Support to Quitting Motivation in Diverse Smokers.

BACKGROUND: Research examining relationships between social support and smoking cessation has paid little attention to non-treatment seeking smokers and not considered the role of autonomy support for fostering quitting motivation. This study examined if autonomy support received from family and friends was associated with quitting motivation and making a quit attempt among diverse smokers with varying levels of quitting motivation. Demographic characteristics associated with autonomy support were explored. METHODS: Participants (N=312) responded to advertisements seeking smokers "not quite ready to quit," and were primarily Black, low-income, and unemployed. Most (255) enrolled in a clinical trial of smoking cessation induction strategies (treatment sample). An additional 57 not meeting the trial eligibility criteria of low quitting motivation enrolled for baseline assessments only. Participants completed baseline measures of autonomy support received from friends and autonomous quitting motivation. In the treatment sample, quit attempts were assessed at 6-months follow-up. RESULTS: Females reported higher levels than males of autonomy support from friends (p=0.003). Participants with a high school diploma/GED reported higher levels of support from family (p<0.001) and friends (p=0.014) than those with less education or a college/graduate degree. Both family (p=0.007) and friend (p=0.004) autonomy support scores were significantly, albeit weakly, associated with autonomous quitting motivation. Autonomy support was not associated with making a quit attempt. CONCLUSIONS: Support from family and friends may promote autonomous reasons to quit among diverse smokers. Research is needed to assess the role of social support in the pre-quitting phases among racial and socio-economically diverse populations.

Improving understanding of the quitting process: psychological predictors of quit attempts versus smoking cessation maintenance among college students.

This study examined motivation, positive and negative outcome expectations of quitting, and self-efficacy as predictors of quit attempts and cessation maintenance in a smoking cessation intervention for college students (N = 303). Psychological measures assessed at baseline were used to predict smoking behavior outcomes. Analysis of variance (ANOVA) and logistic regression analysis revealed that motivation and self-efficacy were strong, differential predictors of quit attempts and cessation maintenance, respectively. This study extends the previous findings regarding psychological predictors of quitting processes to college students, and suggests the need for interventions tailored according to phases of quitting processes.

Motivational Interviewing for encouraging quit attempts among unmotivated smokers: study protocol of a randomized, controlled, efficacy trial.

BACKGROUND: Although the current Clinical Practice Guideline recommend Motivational Interviewing for use with smokers not ready to quit, the strength of evidence for its use is rated as not optimal. The purpose of the present study is to address key methodological limitations of previous studies by ensuring fidelity in the delivery of the Motivational Interviewing intervention, using an attention-matched control condition, and focusing on unmotivated smokers whom meta-analyses have indicated may benefit most from Motivational Interviewing. It is hypothesized that MI will be more effective at inducing quit attempts and smoking cessation at 6-month follow-up than brief advice to quit and an intensity-matched health education condition. METHODS/DESIGN: A sample of adult community resident smokers (N = 255) who report low motivation and readiness to quit are being randomized using a 2:2:1 treatment allocation to Motivational Interviewing, Health Education, or Brief Advice. Over 6 months, participants in Motivational Interviewing and Health Education receive 4 individual counseling sessions and participants in Brief Advice receive one brief in-person individual session at baseline. Rigorous monitoring and independent verification of fidelity will assure the counseling approaches are distinct and delivered as planned. Participants complete surveys at baseline, week 12 and 6-month follow-up to assess demographics, smoking characteristics, and smoking outcomes. Participants who decide to quit are provided with a self-help guide to quitting, help with a quit plan, and free pharmacotherapy. The primary outcome is self-report of one or more quit attempts lasting at least 24 hours between randomization and 6-month follow-up. The secondary outcome is biochemically confirmed 7-day point prevalence cessation at 6-month follow-up. Hypothesized mediators of the presumed treatment effect on quit attempts are greater perceived autonomy support and autonomous motivation. Use of pharmacotherapy is a hypothesized mediator of Motivational Interviewing's effect on cessation. DISCUSSION: This trial will provide the most rigorous evaluation to date of Motivational Interviewing's efficacy for encouraging unmotivated smokers to make a quit attempt. It will also provide effect-size estimates of MI's impact on smoking cessation to inform future clinical trials and inform the Clinical Practice Guideline. TRIAL REGISTRATION: ClinicalTrials.gov NCT01188018.

Parental influence on obesity in Northern Plains American Indian youth.

Little is known regarding American Indian (AI) parental influence on children's diet and physical activity (PA), or if this influence is associated with childhood weight. We compared AI parents' diet, PA, and support for these behaviors with the child's body mass index. Scores for parental support of positive PA and diet were higher among parents of overweight/obese children. Parent PA and nutrition behaviors were in a similar, but not significant, direction with respect to child body mass index. Findings suggest that future research is needed to determine what parental, societal, or community variables influence AI children to engage in healthy eating and PA, especially if they are overweight or obese, and the age at which these variables would have the most impact on these behaviors.

A Systematic Review of Interventions to Increase Physical Activity Among American Indian and Alaska Native Older Adults.

BACKGROUND AND OBJECTIVES: Physical activity (PA) is a powerful protective factor known to reduce risk for chronic conditions across the life span. PA levels are lower among American Indians and Alaska Natives (AIANs) when compared with other racial/ethnic groups and decrease with age. This evidence justifies a synthesis of current intervention research to increase PA levels among AIANs. This systematic review examines completed interventions to increase PA among AIAN older adults and considers recommended practices for research with Indigenous communities. RESEARCH DESIGN AND METHODS: The systematic review was designed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement for systematic review protocols and reporting guidelines. Three electronic databases, PubMed, Web of Science, and PsycINFO, were searched for academic literature. Trials investigating interventions to increase PA among AIAN adults older than 50 years were eligible. The Quality Assessment Tool for Quantitative Studies was used to evaluate the quality of evidence. RESULTS: Three published trials were identified, including one group-level, clinic-based and two individual-level, home-based interventions. All were 6 weeks in duration, took place in urban areas, and used self-report PA measures. Findings indicated an overall increase in PA levels, improved PA-related outcomes, and improved psychosocial health among participants. None described community-engaged or culture-centered research strategies. DISCUSSION AND IMPLICATIONS: The narrow yet promising evidence represents a need for expanded research and a call to action for using culture-centered strategies. An advanced understanding of cultural and contextual aspects of PA may produce more impactful interventions, supporting health and mobility across the life span.

Analysis of smoking patterns and contexts among college student smokers.

Many who smoke in college do so infrequently and smoking conditions are not well understood. We examined smoking patterns among college fraternity and sorority members (N = 207) from a Midwestern university in three successive fall semesters in 2006-2008. Participants completed calendar-assisted retrospective assessments of 30-day smoking at up to five assessment points over 96 days. Overall smoking rates declined over the course of each semester and higher smoking on weekends was observed, with more variability among daily smokers. The most frequent categories of events to cue recall of smoking were socializing, work, and school. Findings can be used to target prevention efforts.

Lessons Learned in Conducting Community Participatory School-Based Health Research on an American Indian Reservation.

BACKGROUND: Describing lessons learned from using a community-based participatory research (CBPR) approach to conduct school-based child health research in a tribal community is an important contribution to the literature. OBJECTIVES: To identify how CBPR principles shaped the process of conducting a school-based child health intervention, and to describe lessons learned. METHODS: The study evaluates how CBPR principles guided a mixed-methods, school-based child health intervention to increase physical activity (PA). RESULTS: Nine key lessons are identified, associated with CBPR principles. CONCLUSIONS: This information can help researchers understand how to successfully navigate the challenges and opportunities of conducting CBPR-guided research in the context of a small, short-term project, including leadership turnover, multiple Institutional Review Board (IRB)s, and study design approaches amidst schools policy changes. Collectively, understanding the lessons learned through the perspective of CBPR principles may help others conduct meaningful research with schools and children in tribal communities.

Uplifting the voices of rural American Indian older adults to improve understanding of physical activity behavior.

American Indian (AI) older adults experience pronounced health disparities and demonstrate one of the lowest levels of physical activity (PA) among racial and ethnic groups. Nearly half of AI older adults live in rural areas, indicating distinct challenges to participation in PA. Research to identify factors influencing PA in this population is missing from the literature, yet is critical to informing culturally relevant PA intervention development and implementation. The purpose was to identify barriers to and facilitators of PA among rural AI older adults using the ecological model and qualitative methods. A community-based approach was used to conduct semi-structured interviews with rural AI older adults. Interview questions were based on a multi-level ecological model. Content analysis was performed, using an iterative coding process to identify findings. The mean age of participants (n = 21) was 66 years. Barriers to and facilitators of PA were identified across ecological model levels. Barriers included factors such as caregiving and community responsibilities, lack of acceptable areas for walking, and overall lack of community-level support for older adult health. Facilitators included a personal connection to the land and ancestors through PA, multigenerational participation, and supportive tribal policies. This study addressed a gap in the literature by identifying barriers to and facilitators of PA among rural AI older adults, which can inform PA intervention development. With barriers and facilitators identified by AI older adults themselves, the voices of those directly affected are uplifted to shape efforts toward addressing longstanding health disparities through relevant public health interventions.

Motivational interviewing for smoking cessation in college students: a group randomized controlled trial.

OBJECTIVE: To examine the efficacy of four individually-delivered Motivational Interviewing counseling sessions for smoking cessation versus a matched intensity comparison condition. METHOD: From 2006-2009, students attending college in the Midwest smoking at least 1 of 30 days were recruited regardless of their interest in quitting. 30 fraternities and sororities were randomized, resulting in 452 participants. RESULTS: No significant differences were found for 30-day cessation between treatment and comparison at end of treatment (31.4% vs 28%, OR=1.20, 95% CI 0.72,1.99) or at follow-up (20.4% vs 24.6%, OR=0.78, 95% CI 0.50,1.22). Predictors of cessation at follow-up, regardless of condition, included more sessions attended (OR 1.2, 95% CI 1.1,1.8) and more cigarettes smoked in 30 days at baseline (OR 4.7, 95% CI 2.5,8.9). The odds of making at least one quit attempt were significantly greater for those in the smoking group at end of treatment (OR 1.75, 95% CI 1.11,2.74) and follow-up (OR 1.66, 95% CI 1.11,2.47). Modeling showed reduction in days smoked for both groups. At end of treatment, more frequent smokers in the treatment condition had greater reductions in days smoked. CONCLUSION: Motivational Interviewing for smoking cessation is effective for increasing cessation attempts and reducing days smoked in the short run.

Strategies to recruit and retain college smokers in cessation trials.

Techniques to recruit and retain college fraternity and sorority members who reported past 30-day smoking into a cessation trial are described. Recruitment efforts included relationship-building, raffles, and screening survey administration during existing meetings. Surveys were administered to 76% (n = 3,276) of members in 30 chapters, 79% of eligible members agreed to participate, and 76% of those completed assessments and were enrolled in the trial (n = 452). The retention rate was 73%. Retention efforts included cash incentives, flexible scheduling, multiple reminders, chapter incentives, and use of chapter members as study personnel. Retention was not related to demographic, behavioral, or group characteristics. The strategies of partnership, convenience, and flexibility appear effective and may prove useful to investigators recruiting similar samples.

Tobacco treatment practices of pharmacists in Montana.

OBJECTIVES: To assess the tobacco treatment practices of Montana pharmacists, evaluate pharmacist interest in addressing tobacco use, and identify perceived barriers to delivery of tobacco cessation services. DESIGN: Descriptive, nonexperimental, cross-sectional study. SETTING: Montana in February 2007. PARTICIPANTS: 192 pharmacists attending an annual continuing professional education program. INTERVENTION: Attendees at 11 meeting sites throughout the state completed the survey. MAIN OUTCOME MEASURES: Pharmacists' use of the U.S. Clinical Practice Guideline 5 A's (ask, advise, assess, assist, and arrange) in regard to tobacco cessation services. RESULTS: Of program attendees, 76% (192 of 253) completed the 35-item survey. More than one-half (58%) of respondents were men, and 90% were white. Respondents were licensed for a median of 22.5 years and dispensed a median of 1,000 prescriptions per week. The percent of pharmacists who treated one or more patients using the 5 A's in the preceding 30 days were as follows: asked about tobacco use, 39%; advised to quit smoking, 54%; assessed for readiness to quit smoking, 36%; assisted with quitting (i.e., cessation counseling), 46%; assisted with advice to use nonprescription cessation medication, 62%; assisted with advice to use prescription cessation medication, 54%; arranged for a follow-up appointment for additional counseling, 6%; and referred to a tobacco quit line, 23%. Most respondents (58%) reported that providing cessation services within routine practice was moderately or highly feasible. The most frequently cited barriers to providing cessation services included lack of time (52%), reimbursement (26%), and training (19%). CONCLUSION: Few Montana pharmacists are routinely asking patients about tobacco use in a typical month. However, the majority of pharmacists reported that it would be feasible to provide more tobacco cessation activities within routine pharmacy practice. Addressing barriers related to workload, reimbursement, and training would likely increase the number of pharmacists who provide tobacco cessation services.

Adaptation of a lay health advisor model as a recruitment and retention strategy in a clinical trial of college student smokers.

This study describes and provides results from a process evaluation of a lay health advisor (LHA) model to enhance participation in a clinical trial of the effectiveness of motivational interviewing on smoking cessation in college fraternity and sorority members. The implementation of the model had two phases: (a) the selection and training of LHAs as liaisons between research staff and participants and (b) LHAs' roles in recruitment and retention. Perceptions of the LHA model were explored using survey questionnaires. Trial participants (N = 118) and LHAs (N = 8) were generally satisfied with the model and identified LHAs as helpful to participation. Seventy-four percent of chapter members were screened and 73% of participants received three of the four motivational interviewing sessions. These results indicate the LHA model was well received and met the needs of the research project.

Race moderates the effects of Motivational Interviewing on smoking cessation induction.

OBJECTIVE: Health disparities necessitate exploration of how race moderates response to smoking cessation treatment. Data from a randomized clinical trial of Motivational Interviewing (MI) for smoking cessation induction were used to explore differential treatment response between African American (AA) vs Non-Black (NB) smokers. METHODS: Adult tobacco smokers (138 AA vs 66 NB) with low desire to quit were randomly assigned to four sessions of MI or health education (HE). Outcomes (e.g., quit attempts) were assessed 3- and 6-months. RESULTS: There was evidence of a Race by Treatment interaction such that MI was less effective than HE in AA smokers. Mean Cohen's d for the interaction effect was -0.32 (95% CI [-0.44, -0.20]). However, the race interaction could be accounted for by controlling for baseline relationship status and communication preference (wants directive approach). CONCLUSIONS: MI may be less effective for smoking cessation induction in AA vs NB smokers when compared to another active and more directive therapy. The differential response between races may be explained by psychosocial variables. PRACTICE IMPLICATIONS: MI may not be an ideal choice for all African American smokers. Patients' relationship status and preference for a directive counseling approach might explain disparities in response to MI treatment.

Randomized trial assessing the effectiveness of a pharmacist-delivered program for smoking cessation.

BACKGROUND: As trained and accessible healthcare professionals, pharmacists are in an ideal position to provide tobacco cessation interventions. Of the 15 studies identified in the literature assessing the effectiveness of tobacco cessation interventions delivered by pharmacists, this is the first randomized controlled trial conducted in the US of a pharmacist-delivered program for smoking cessation using biochemical confirmation. OBJECTIVE: To assess the effectiveness on smoking cessation of a face-to-face group program conducted by the pharmacist team compared with a brief standard care session delivered by a pharmacist over the telephone. METHODS: An open-label, prospective, randomized, controlled trial was conducted at a Veterans Health Administration, community-based outpatient clinic in the Rocky Mountain region. Participants were randomly assigned to receive a 3-session face-to-face group program conducted by the pharmacist team or one 5- to 10-minute standard care session delivered by the pharmacist team over the telephone. Participants in both groups were offered either immediate-release bupropion or nicotine patch at no cost. The primary outcome of self-reported abstinence was biochemically confirmed by urinary cotinine at 6 months after the quit date. RESULTS: One hundred one smokers were randomized from October 3, 2005, to March 30, 2007, with the last 6-month follow-up survey completed on November 6, 2007. Analysis of data was completed in December 2007. Using intent-to-treat procedures, confirmed abstinence rates at the end of 6 months were 28% in the pharmacist-delivered face-to-face treatment group and 11.8% in the standard care telephone session control group (p < 0.041). CONCLUSIONS: This study demonstrates that pharmacists are effective providers of tobacco cessation interventions. Greater utilization of pharmacists in tobacco cessation efforts could have a significant impact on smoking rates, prevention of tobacco-related diseases, and overall improvement in public health across the US.

Timeline follow-back versus global self-reports of tobacco smoking: a comparison of findings with nondaily smokers.

Methods assessing nondaily smoking are of concern because biochemical measures cannot verify self-reports beyond 7 days. This study compared 2 self-reported smoking measures for nondaily smokers. A total of 389 college students (48% women, 96% White, mean age=19 years) smoking between 1 and 29 days out of the past 30 completed computer assessments in 3 cohorts, with the order of administration of the measures counterbalanced. Values from the 2 measures were highly correlated. Comparisons of timeline follow-back (TLFB) with the global questions for the total sample of nondaily smokers yielded statistically significant differences (p<.001), albeit small, between measures with the TLFB resulting on average in 2.38 more total cigarettes smoked out of the past 30 days, 0.46 fewer smoking days, and 0.21 more cigarettes smoked per day. Analyses by level of smoking showed that the discordance between the measures differed by frequency of smoking. Global questions of days smoked resulted in frequent reporting in multiples of 5 days, suggesting digit bias. Overall, the 2 measures of smoking were highly correlated and equally effective for identifying any smoking in a 30-day period among nondaily smokers.

Cultural identification and smoking among American Indian adults in an urban setting.

OBJECTIVES: Among American Indians (AIs), an important relationship has been theorized between cultural identification and substance abuse, including smoking. We investigated the relationship between cultural identification and smoking among AI adults. DESIGN: Using the Orthogonal Cultural Identification Scale (OCIS), we examined the relationship between AI and White cultural identification and cigarette use in a sample of AI recruited at an urban Indian center (n=217). RESULTS: We found that high AIs identification predicted smoker status and high White identification predicted non-smoker status when controlling for age and reservation residence. Orthogonal cultural identification status (categorized as high White/high AI, high White/low AI, low White/high AI, or low White/low AI) did not predict smoker status when controlling for age and reservation residence. OCIS item analysis revealed that positive responses to the individual OCIS items 'My family lives by the American Indian way of life,' 'I live by the American Indian way of life,' and 'I am a success in the American Indian way of life' predicted smoker status when controlling for age and reservation residence. CONCLUSIONS: Our data suggest that, among some groups of urban AIs, recreational smoking is associated with AI cultural identification.

The role of depression and negative affect regulation expectancies in tobacco smoking among college students.

OBJECTIVE: Expectancies about nicotine's ability to alleviate negative mood states may play a role in the relationship between smoking and depression. The authors examined the role of negative affect regulation expectancies as a potential mediator of depression (history of depression and depressive symptoms) and smoking among college students. PARTICIPANTS AND METHODS: As part of a larger study, 315 undergraduate smokers completed a 296-item survey from January to May of 2001 and 2002. RESULTS: Cross-sectional analyses revealed that negative affect regulation expectancies fully mediated the positive relationship between depressive symptoms and level of smoking. CONCLUSIONS: Although depressive symptoms are associated with higher levels of tobacco smoking, the expectation that smoking will reduce negative emotions is 1 factor that accounts for this relationship.

Use of the Quality of Life Inventory for measuring quality of life changes in an inpatient psychiatric population.

This study measured self-reported quality of life at two time points for 50 diagnostically heterogeneous patients in a state-funded psychiatric hospital and evaluated the Quality of Life Inventory for assessing changes over inpatient treatment. Participants completed the Quality of Life Inventory after admission and before discharge. Improvement occurred in overall scores during participants' hospital stays. Analysis of domains showed improvements in satisfaction with health and self-esteem. The inventory appears a useful tool for evaluating outcomes of psychiatric inpatient treatment from a patient perspective.