Application of the Capabilities, Opportunities, Motivations, and Behavior (COM-B) Change Model to Formative Research for Child Nutrition in Western Kenya.

Background: Interventions aimed at improving dietary intake and feeding practices have alone proven insufficient for combatting stunting resulting from poor nutrition and repeated infections. Objectives: To support the development of an integrated water, sanitation, and hygiene (WASH) and nutrition, social, and behavior change strategy aimed at reducing stunting, formative research was conducted in 2 program sites in western Kenya. Methods: Twenty-nine key informant interviews were conducted with community leaders, health workers, and project staff, and 24 focus group discussions with caregivers of children under 2 y on topics related to feeding, sanitation, and hygiene behaviors. Three frameworks informed the study design and analysis of our formative research: the Capabilities, Opportunities, and Motivations model for behavior change, which identifies what needs to change in order for behavior change interventions to be effective; the Grandmother Project's Change Through Culture Approach, which values the important role of influential household and community members in producing household health; and Starr and Fornoff's approach to Theory of Change development. Results: Caregivers exhibited sufficient psychological capabilities (knowledge and skills) for many of the key maternal and infant nutrition behaviors. However, reflective motivation to perform optimal behaviors was undermined by limitations in physical and social opportunities, including limited time and competing priorities for mothers, limited accessibility and availability of diverse foods, low self-efficacy for exclusive breastfeeding, and fears of negative consequences related to specific foods and recommended practices. Conclusions: Interventions that aim to improve maternal and child diets should address the underlying social, cultural, and environmental determinants that contribute to motivations and opportunities to perform recommended practices.

Social Environmental Correlates of Health Behaviors in a Faith-Based Policy and Environmental Change Intervention.

Diet and physical activity are behavioral risk factors for many chronic diseases, which are among the most common health conditions in the United States. Yet most Americans fall short of meeting established dietary and physical activity guidelines. Faith-based organizations as settings for health promotion interventions can affect members at multiple levels of the social ecological model. The present study investigated whether change in the church social environment was associated with healthier behavior at church and in general at 1-year follow-up. Six churches received mini-grants and technical assistance for 1 year to support policy and environmental changes for healthy eating (HE) and physical activity (PA). Socioenvironmental (social support and social norms) and behavioral (HE and PA at church and in general) outcomes were derived from baseline and 1-year follow-up church member surveys ( n = 258). Three of six churches demonstrated significant improvements in all three socioenvironmental aspects of HE. Two of five churches exhibited significant socioenvironmental improvements for PA at follow-up. Church social environmental changes were related to health behaviors at church and in general ( p < .05). Change in social support for HE, social support for PA, and social norms for PA were each associated with three church-based and general behavioral outcomes. Social norms for healthy eating were related to two general behavior outcomes and social norms for unhealthy eating to one general behavioral outcome. Study findings demonstrate that socioenvironmental characteristics are essential to multilevel interventions and merit consideration in designing policy and environmental change interventions.

Implementation of a Web-Based Organ Donation Educational Intervention: Development and Use of a Refined Process Evaluation Model.

BACKGROUND: The lack of available organs is often considered to be the single greatest problem in transplantation today. Internet use is at an all-time high, creating an opportunity to increase public commitment to organ donation through the broad reach of Web-based behavioral interventions. Implementing Internet interventions, however, presents challenges including preventing fraudulent respondents and ensuring intervention uptake. Although Web-based organ donation interventions have increased in recent years, process evaluation models appropriate for Web-based interventions are lacking. OBJECTIVE: The aim of this study was to describe a refined process evaluation model adapted for Web-based settings and used to assess the implementation of a Web-based intervention aimed to increase organ donation among African Americans. METHODS: We used a randomized pretest-posttest control design to assess the effectiveness of the intervention website that addressed barriers to organ donation through corresponding videos. Eligible participants were African American adult residents of Georgia who were not registered on the state donor registry. Drawing from previously developed process evaluation constructs, we adapted reach (the extent to which individuals were found eligible, and participated in the study), recruitment (online recruitment mechanism), dose received (intervention uptake), and context (how the Web-based setting influenced study implementation) for Internet settings and used the adapted model to assess the implementation of our Web-based intervention. RESULTS: With regard to reach, 1415 individuals completed the eligibility screener; 948 (67.00%) were determined eligible, of whom 918 (96.8%) completed the study. After eliminating duplicate entries (n=17), those who did not initiate the posttest (n=21) and those with an invalid ZIP code (n=108), 772 valid entries remained. Per the Internet protocol (IP) address analysis, only 23 of the 772 valid entries (3.0%) were within Georgia, and only 17 of those were considered unique entries and could be considered for analyses. With respect to recruitment, 517 of the 772 valid entries (67.0%) of participants were recruited from a Web recruiter. Regarding dose received, no videos from the intervention website were watched in their entirety, and the average viewing duration was 17 seconds over the minimum. With respect to context, context analysis provided us with valuable insights into factors in the Internet environment that may have affected study implementation. Although only active for a brief period of time, the Craigslist website advertisement may have contributed the largest volume of fraudulent responses. CONCLUSIONS: We determined fraud and low uptake to be serious threats to this study and further confirmed the importance of conducting a process evaluation to identify such threats. We suggest checking participants' IP addresses before study initiation, selecting software that allows for automatic duplicate protection, and tightening minimum requirements for intervention uptake. Further research is needed to understand how process evaluation models can be used to monitor implementation of Web-based studies.

Promoting Policy and Environmental Change in Faith-Based Organizations: Description and Findings From a Mini-Grants Program.

PURPOSE: The Emory Prevention Research Center's Cancer Prevention and Control Research Network mini-grant program funded faith-based organizations to implement policy and environmental change to promote healthy eating and physical activity in rural South Georgia. This study describes the existing health promotion environment and its relationship to church member behavior. DESIGN: Cross-sectional. SETTING: Data were obtained from parishioners of six churches in predominantly rural South Georgia. SUBJECTS: Participants were 319 church members with average age of 48 years, of whom 80% were female and 84% were black/African-American. MEASURES: Questionnaires assessed perceptions of the existing church health promotion environment relative to nutrition and physical activity, eating behavior and intention to use physical activity facilities at church, and eating and physical activity behaviors outside of church. ANALYSIS: Multiple regression and ordinal logistic regression using generalized estimating equations were used to account for clustered data. RESULTS: Results indicate that delivering messages via sermons and church bulletins, having healthy eating programs, and serving healthy foods are associated with participants' self-reported consumption of healthy foods at church (all p values ≤ .001). Serving more healthy food and less unhealthy food was associated with healthier eating in general but not to physical activity in general (p values ≤ .001). CONCLUSION: The church environment may play an important role in supporting healthy eating in this setting and more generally.

Practice to Evidence: Using Evaluability Assessment to Generate Practice-Based Evidence in Rural South Georgia.

Evidence from formal evaluation of real-world practice can address gaps in the public health knowledge base and provide information about feasible, relevant strategies for varied settings. Interest in evaluability assessment (EA) as an approach for generating practice-based evidence has grown. EA has been central to several structured assessment processes that identify and select promising programs and evaluate those most likely to produce useful findings. The Emory Prevention Research Center used EA as part of an initiative to generate practice-based evidence for cancer prevention in southwest Georgia. Our initiative consisted of five steps: (1) environmental scan to identify potential programs, (2) program selection, (3) EA, (4) evaluation, and (5) dissemination. We identified nine programs, four of which completed a formal application, and conducted two EAs. EAs consisted of document review, site visits, and literature reviews. The EA purpose was to assess the program model, data availability, stakeholder interest in evaluation, feasibility of an outcome evaluation, and potential contribution to the literature. We conducted one outcome evaluation and one descriptive qualitative study; both were published in peer-reviewed journals. The outcome evaluation addressed knowledge gaps about strategies to promote colorectal cancer screening. Results led to the program's inclusion in national resources for practitioners seeking evidence-based practices and helped the community organization expand and strengthen the program. As part of a structured assessment process, EA can identify programs most likely to produce useful results for dissemination and is a viable approach for local initiatives to generate practice-based evidence in rural or low-resource settings.

The Inclusion of African-American Study Participants in Web-Based Research Studies: Viewpoint.

The use of Web-based methods for research recruitment and intervention delivery has greatly increased as Internet usage continues to grow. These Internet-based strategies allow for researchers to quickly reach more people. African-Americans are underrepresented in health research studies. Due to this, African-Americans get less benefit from important research that could address the disproportionate health outcomes they face. Web-based research studies are one promising way to engage more African-Americans and build trust with the African-American community. With African-Americans' increasing access to the Internet using mobile phones and other mobile phone technologies, we advocate for efforts to increase the representation of African-Americans in research studies by using the Internet as a recruitment tool and conclude with recommendations that support this goal.

Living donor transplant education for African American patients with end-stage renal disease.

CONTEXT: Despite numerous benefits of live donor kidney transplant (LDKT), patient-level barriers often prevent African Americans from considering LDKT. Educational interventions designed to address patient-level barriers may increase willingness among African American patients with end-stage renal disease to explore LDKT as a treatment option. OBJECTIVE: To assess the effectiveness of a culturally sensitive educational intervention called Living ACTS (About Choices in Transplantation and Sharing) that was designed to address patient-level barriers to LDKT among African American patients with end-stage renal disease. DESIGN/PARTICIPANTS: Patients were randomized to intervention (n = 136) or control (n = 132) groups. They completed baseline measures and then viewed either the Living ACTS or control video. Both groups then completed an immediate follow-up measure and a 6-month assessment administered via telephone. MAIN OUTCOME MEASURES: Self-reported knowledge about LDKT, willingness to talk to the patient's family about LDKT, and perceived benefits of LDKT were measured at 3 time points. RESULTS: At 6-month follow-up, intervention participants demonstrated a significantly greater increase in knowledge of LDKT than control participants (F2,229=3.08, P= .05). Intervention participants expressed greater willingness to talk to patients' families about LDKT than did control participants from baseline through 6-month follow-up (F1,230 = 7.11, P= .008). Finally, at immediate follow-up, intervention participants reported greater endorsement of the benefits of LDKT than did control participants (F2,223 = 14.27, P< .001); however, this effect had disappeared by the 6-month follow-up. CONCLUSIONS: Living ACTS is effective at increasing and maintaining knowledge about LDKT among African American patients with end-stage renal disease who are considering transplant.

Understanding African American's religious beliefs and organ donation intentions.

African Americans are overrepresented on the organ transplant waiting list and underrepresented among organ and tissue donors. One of the most highly noted reasons for lack of donation is the perception that donation is contrary to religious beliefs. The purpose of this cross-sectional study is to explore the complexities of religion (beliefs, religiosity, and religious involvement) and its association with willingness to donate and the written expression of donation intentions. Findings from a sample of 505 African American participants suggest that religion is a multidimensional construct and results differ depending on how the construct is measured and operationalized.

Understanding the relationship between trust in health care and attitudes toward living donor transplant among African Americans with end-stage renal disease.

Transplantation is the favored therapy for patients with end-stage renal disease (ESRD). Unfortunately, demand for available organs far outpaces the supply. African Americans are disproportionately affected by the ever-widening gap between organ supply and demand. Additionally, structural, biological, and social factors contribute to feelings of unease some African Americans may feel regarding living donor transplant (LDT). The present research examines the relationship between trust in health care and attitudes toward LDT among African American ESRD patients. We hypothesized that lower trust in health care would be significantly associated with negative attitudes toward LDT, and that this relationship would be moderated by patient attitudes toward dialysis. Data were collected from August 2011 to April 2012 as part of a larger study. Measures included trust (of doctors, racial equity of treatment, and hospitals) and attitudes toward both LDT and dialysis. Bivariate analysis revealed that trust in one's doctor, hospital, and in racial equity in health care was significantly correlated with attitudes toward LDT (r = 0.265; r = 0.131; and r = 0.202, respectively). Additionally, attitudes toward dialysis moderated the relationships between Trust in Doctors/Attitudes toward LDT and Trust in Racial equity of treatment/Attitudes toward LDT. Findings suggest a strong relationship between trust in health care and attitudes toward LDT. These findings also shed light on how dialysis experiences are related to the relationship between trust in health care and attitudes toward LDT.

Project ACTS II: organ donation education for African American adults.

OBJECTIVE: Project ACTS "About Choices in Transplantation and Sharing" is a culturally sensitive intervention designed to address organ donation concerns among African American adults. Our study sought to evaluate the efficacy of two versions of the Project ACTS intervention and to determine whether reviewing materials in a group setting would be more effective at increasing participants' interest in organ and tissue donation than allowing participants to review the materials at home with friends and family. DESIGN: A pre-post simple factorial experimental design was used to assess differences between intervention package (Project ACTS I vs II) and mode of delivery (group vs take home). METHODS: Participants completed a baseline and 1-year follow-up assessment of donation-related knowledge, attitudes, and interest. MAIN OUTCOME MEASURES: A summed score that represents participants' interest in being recognized as an organ donor on their driver's license, via donor card, and by talking to family. RESULTS: From baseline to follow-up, participants increased their knowledge, attitudes, and interest in being recognized as an organ donor regardless of intervention package (Ps<.05). Regarding setting, participants who reviewed materials in a group setting demonstrated greater increase from baseline to follow-up in interest in organ donation (beta=.22, P<.01) and positive attitudes toward donation (beta=.22, P<.05) than those who were allowed to review materials at home with friends and family. CONCLUSION: Project ACTS I and II are equally efficacious; reviewing the intervention in a group setting may be necessary for low vested interest/high ambivalence health behaviors such as organ donation.

Evaluation of the Avon Foundation community education and outreach initiative Community Patient Navigation Program.

INTRODUCTION: Black women in the United States experience disproportionate breast cancer mortality. Culturally appropriate community education on the importance of breast health coupled with the availability of free or low-cost mammography screening services may help improve the use of mammography screening services among Black women. The Avon Foundation Community Patient Navigation Program seeks to fill this need. The current study presents a process and outcome evaluation of this program. METHOD: Trained and uniformed community patient navigators (PNs) host breast health education events where they recruit community members to complete a mammography interest form. Participants are referred to a nurse practitioner who determines eligibility for a free or low-cost mammogram. The community PN delivers telephone follow-up to encourage participants to make and keep their mammogram appointments. RESULTS: Over a 15-month period, 22 community PNs hosted 207 breast health events, which included 9,601 attendees. Three hundred and four participants completed a mammography interest form, and 21% of these individuals received mammograms at the collaborating health facility. Participants who reported breast symptoms were twice as likely to get a mammogram as those who did not report symptoms. DISCUSSION: Community patient navigation may be a useful resource for encouraging mammography screening among underserved women.

Testing the utility of a modified organ donation model among African American adults.

African Americans are overrepresented on the organ transplant waiting list because they are disproportionately impacted by certain health conditions that potentially warrant a life-saving transplant. While the African American need for transplantation is considerably high, organ and tissue donation rates are comparatively low, resulting in African Americans spending more than twice the amount of time on the national transplant waiting list as compared to people of other racial/ethnic backgrounds. There are a multitude of factors that contribute to the reluctance expressed by African Americans with respect to organ donation. This study proposes the use of an adaptation of the Organ Donation Model to explore the ways in which knowledge, trust in the donation/allocation process, and religious beliefs impact African American donation decision making. Bivariate and path analyses demonstrated that alignment with religious beliefs was the greatest driving factor with respect to attitudes towards donation; attitudes were significantly associated with donation intentions; and knowledge is directly associated with intentions to serve as a potential deceased organ donor. The significance of these variables speaks to the importance of their inclusion in a model that focuses on the African American population and offers new direction for more effective donation education efforts.

Distrust in the healthcare system and organ donation intentions among African Americans.

The purpose of this study is to further understanding of the association between distrust in the healthcare system and written and verbal expressions of donation intentions among African Americans. We hypothesize that distrust in the healthcare system will be significantly, positively associated with both verbal and written donation intentions. Five hundred and eighty five participants completed a 98-item survey that included scales on distrust in the healthcare system and donation intentions. Bivariate analyses (t-tests, ANOVA, chi-square tests and odds ratios) were used to explore the extent to which donation intentions and distrust in the healthcare system varied by demographic characteristics and the association between the distrust in the healthcare system scale and verbal and written donation intentions. Separate logistic regressions were performed with each of the dependent variables to see if significant associations remained while controlling for confounders. Findings based on the multiple regression indicate that when controlling the participant's education level, distrust in the healthcare system was not significantly related to written donation intentions (OR = 1.04; P = .12). When controlling for education level, health insurance status, Community Health Advocates group and marital status, distrust in the healthcare system was significantly associated with verbal donation intentions (OR = 1.08; P < 0.05). Our results suggest that distrust in the healthcare system varies in the way that it is associated with donation intentions. Future organ donation studies should be conducted to determine the pathways through which distrust in the healthcare system impacts different types of organ donation intentions.

Residential racial composition, spatial access to care, and breast cancer mortality among women in Georgia.

We explored the association between neighborhood residential racial composition and breast cancer mortality among Black and White breast cancer patients in Georgia and whether spatial access to cancer care mediates this association. Participants included 15,256 women living in 15 metropolitan statistical areas in Georgia who were diagnosed with breast cancer between 1999 and 2003. Residential racial composition was operationalized as the percent of Black residents in the census tract. We used gravity-based modeling methods to ascertain spatial access to oncology care. Multilevel Cox proportional hazards models and mediation analyses were used to test associations. Black women were 1.5 times more likely to die from breast cancer than White women. Residential racial composition had a small but significant association with breast cancer mortality (hazard ratios [HRs] = 1.04-1.08 per 10% increase in the percent of Black tract residents). Individual race did not moderate this relationship, and spatial access to care did not mediate it. Residential racial composition may be part of the socioenvironmental milieu that produces increased breast cancer mortality among Black women. However, there is a lack of evidence that spatial access to oncology care mediates these processes.

Correlates of support for living donation among African American adults.

CONTEXT: Living donation is studied with much less intensity among African Americans than among the general population. Examination of barriers to living donation can lead to effective strategies to educate dialysis patients and their families about this alternative. OBJECTIVE: To explore the correlates of likelihood of becoming a living donor among community-recruited African American adults. DESIGN/PARTICIPANTS: Cross-sectional data were gathered via self-administered questionnaire from 425 African American adults, age 18 years and older, who were recruited from 9 churches in Atlanta. MAIN OUTCOME MEASURES: Self-reported likelihood of becoming a living donor to a close family member, an extended family member or friend, or a stranger. RESULTS: More than three-quarters of participants were willing to act as living donors to a close family member or spouse and two-thirds to friends or extended family. For likelihood of donating to a friend or extended family member, only willingness to engage in deceased donation was significantly associated; to a stranger, both willingness to engage in deceased donation and attitudes toward donation were significantly associated. Knowledge of and personal experiences with donation and/or transplantation were not significantly associated with likelihood of any type of living donation. CONCLUSIONS: Findings indicate widespread support for living donation to a close family member or spouse. These findings have important implications for dialysis patients who must decide whether to approach friends and/or family about the possibility of serving as a living donor and emphasize the need for interventions to help facilitate this process.

Health literacy and control in the medical encounter: a mixed-methods analysis.

BACKGROUND: Physician-patient communication can be described according to 4 prototypes of control--paternalism, mutuality, consumerism, or default. Patients with inadequate health literacy skills may be less-active participants in their care and more likely to have paternalistic encounters. METHODS: Two independent coders analyzed 31 transcribed outpatient medical visits between physicians and African American patients with diabetes according to the 4 prototypes of control. Differences in communication and the balance of power by level of patients' health literacy were analyzed by quantitative and qualitative methods. RESULTS: Fourteen patients (45%) had inadequate health literacy, and most of them (N=8, 57%) had paternalistic encounters. Among patients with marginal or adequate health literacy skills, only 4 (23%) had paternalistic visits (p = .06), and encounters marked by mutuality were most common (N= 9, 53%). CONCLUSION: Patients with inadequate health literacy appear more likely to have paternalistic interactions with their physicians.

Reliability and validity of the alcohol consequences expectations scale.

OBJECTIVES: To examine the reliability and validity of a new measure of alcohol outcome expectations for college students, the Alcohol Consequences Expectations Scale (ACES). METHODS: College students (N=169) completed the ACES and several other measures. RESULTS: Results support the existence of 5 internally consistent subscales. Additionally, the ACES is associated with conceptually similar measures and self-reported drinking behavior. CONCLUSIONS: This study supports the reliability of the ACES and its subscales and provides preliminary evidence of construct and criterion-related validity. Pending further investigation, this scale may be used to inform the development of alcohol abuse prevention programs on college campuses.

Understanding the role of clergy in African American organ and tissue donation decision-making.

OBJECTIVES: To describe and understand the attitudes, beliefs, and experiences towards organ and tissue donation among African American clergy in Atlanta, Georgia, USA. The secondary objective is to understand what messages clergy are providing to their parishioners relative to organ and tissue donation, and what their perceived role is in donation education. DESIGN: A qualitative study in which African American clergy (n=26) participated in four focus groups. RESULTS: African American clergy, though generally supportive of organ and tissue donation in principle, have serious reservations about donation due to perceived inequalities in the donation and transplantation system. The clergy did not personally hold religious concerns about donation, but expressed that these concerns were a major barrier to donation among their parishioners. None of the clergy knew the written position that their religion took on donation; they acknowledged the need for more education for them and their parishioners on this topic. They also felt that as religious leaders, they could play an important role in promoting organ and tissue donation among African American parishioners. CONCLUSIONS: African American clergy and religious leaders may play an important role towards improving willingness to donate among African American parishioners, but more education and advocacy is needed to prepare them for this role.