Implementation and evaluation of Exercise is Medicine in primary care clinics within a large academic health system.

OBJECTIVE: Exercise is Medicine (EIM) is a global initiative encouraging healthcare providers to routinely assess and promote physical activity (PA) among patients. The objective of this study was to evaluate the feasibility, adoption, implementation and effectiveness of EIM from patient, clinician and healthcare staff perspectives using a combination of electronic health record (EHR), survey and interview data. DESIGN: This study used a combination of the Practical Robust Implementation and Sustainability Model (PRISM) and the Learning Evaluation model to implement EIM. Data captured from the EHR, including Physical Activity Vital Sign (PAVS) scores, and data collected from qualitative surveys and interviews were used to evaluate the programme's Reach, Effectiveness, Adoption, Implementation, Maintenance (RE-AIM, which is embedded within PRISM) from provider, staff and patient perspectives. SETTING: Five primary care clinics within a large academic health system. PARTICIPANTS: A total of 24 443 patients from all participating clinics had at least one PAVS score during the study period. A total of 17 clinicians completed surveys, and 4 clinicians, 8 medical assistants and 9 patients completed interviews. RESULTS: Implementation fidelity metrics varied widely between components and across clinics but were generally consistent over time, indicating a high degree of programme maintenance. Fidelity was highest during the first 6 months of the COVID-19 pandemic when most visits were virtual. Mean PAVS scores increased from 57.7 (95% CI: 56 to 59.4) to 95.2 (95% CI: 91.6 to 98.8) min per week at 6 months for patients not meeting PA guidelines at baseline and decreased from 253.84 (95% CI: 252 to 255.7) to 208.3 (95% CI: 204.2 to 212.4) min per week at 6 months for patients meeting PA guidelines at baseline. After EIM implementation, clinician-estimated time spent discussing PA with patients increased for 35% of providers and stayed the same for 53%. CONCLUSION: Overall, this study established EIM's feasibility, adoption, implementation and maintenance in routine primary care practice within a large academic health system. From a population health perspective, EIM is a model to emulate to help primary care providers efficiently address healthy lifestyle behaviours in routine primary care visits.

Strategies to Bridge Equitable Implementation of Telehealth.

During the COVID-19 pandemic, the rapid scaling of telehealth limited the extent to which proactive planning for equitable implementation was possible. The deployment of telehealth will persist in the postpandemic era, given patient preferences, advances in technologies, growing acceptance of telehealth, and the potential to overcome barriers to serve populations with limited access to high-quality in-person care. However, aspects and unintended consequences of telehealth may leave some groups underserved or unserved, and corrective implementation plans that address equitable access will be needed. The purposes of this paper are to (1) describe equitable implementation in telehealth and (2) integrate an equity lens into actionable equitable implementation.

Pasos Hacia La Salud II: study protocol for a randomized controlled trial of a theory- and technology-enhanced physical activity intervention for Latina women, compared to the original intervention.

BACKGROUND: Latinas are at increased risk for many lifestyle-related chronic diseases and are one of the least physically active populations in the US Innovative strategies are needed to help Latinas achieve the health benefits associated with physical activity (PA). This manuscript describes the study protocol of the Pasos Hacia La Salud II Study, which builds upon our previous research to test an enhanced individually-tailored, text-message and website-delivered, Spanish-language intervention (enhanced intervention), in comparison to the original web-based Pasos Hacia La Salud Intervention (original intervention). METHODS: Sedentary Latinas between the ages of 18-65 will be recruited and will complete an orientation and baseline assessments. Participants will be subsequently randomized to the original intervention, or the Enhanced Intervention, which has greater targeting of theoretical constructs such as self-efficacy, enjoyment, and social support, and which uses text messages and more dynamic and refined website features to encourage increased website use. Using a linear mixed effects regression model, we will simultaneously estimate the intervention effects on mean accelerometer-measured hours/week of moderate-to-vigorous PA (MVPA) at 6, 12, 18, and 24 months, with a subject-specific intercept (intent-to-treat sample). Change in self-reported MVPA, measured via the 7-day Physical Activity Recall, will be assessed as a secondary outcome using a similar model. We will investigate potential mediators of the intervention effect using a multiple mediation approach, and potential moderators by evaluating potential interactions. As an exploratory outcome, we will study the differences (among both study arms) in cost, in US dollars, per minute increases in weekly mean MVPA. DISCUSSION: The original Pasos PA intervention showed efficacy in helping Latinas increase PA; we expect the Enhanced Intervention to help a larger proportion of participants to increase and maintain their PA long term. This web- and text-based enhanced intervention could have great reach and dissemination potential, which could be capitalized on in the future to help to advance health equity. Adaptations made in response to the COVID-19 pandemic are also described in this manuscript. TRIAL REGISTRATION: Clinical Trial Number: NCT03491592 . First posted April 9, 2018.

Patient feedback and evaluation measures of a physical activity initiative: Exercise is Medicine program.

BACKGROUND: Nearly half of American adults fail to meet national guidelines for physical activity (PA). As a major contributor to the development of preventable chronic diseases, insufficient PA is an important target for health behaviour interventions. Exercise is Medicine (EIM) aims to increase PA levels among primary care patients through routine PA evaluation, prescription, brief counselling, and referral to community resources. PA is treated as a vital sign with the goal of increasing PA levels in prescribed manageable doses. EIM is currently being implemented in UC San Diego Health System's primary care clinics. OBJECTIVE: (i) To collect and summarize patient perceptions of EIM and its components. (ii) To identify discrepancies between patient-reported feedback and primary care provider (PCP) documentation in corresponding visit notes in the electronic medical record (EMR). METHODS: Patient recall of EIM components was measured using a 10-item survey distributed via MyChart. PCP documentation of EIM was tracked in the EMR system. RESULTS: Patient feedback (n = 316) about EIM components was positive and reinforced patients' confidence in their ability to increase PA. Approximately 70% of patients reported having a PA discussion with their PCP at their most recent visit, but only approximately 21% of these discussions were documented by PCPs using the preprogrammed smartphrase in the EMR. CONCLUSION: Overall, patients reported positive perceptions of EIM. While patient perceptions of EIM suggested that PA discussions with PCPs are happening during the majority of visits, PCP documentation fell behind. Documentation via smartphrase may need to be modified for physicians to use.

The Exercise is Medicine (EIM) program encourages primary care patients to increase their weekly physical activity (PA). The program includes an initial PA evaluation, prescription, counselling, and referral to community resources. EIM is currently active at UC San Diego Health System's primary care clinics. In this study, patient feedback of program components is collected and physician documentation in the electronic medical records system is evaluated. Overall, feedback was positive with patients reporting high levels of self-confidence in their ability to increase their weekly PA. Patients indicated that PA was discussed at roughly 70% of all recent visits. However, physician documentation indicated that PA was discussed at approximately 21% of all recent visits. Although PA was successfully addressed, documentation may need to be modified to more accurately reflect EIM program usage.

Long-term physical activity outcomes in the Seamos Activas II trial.

Latinas report disproportionately low physical activity (PA) levels and related health conditions. Reducing chronic disease in Latinas requires interventions to increase and maintain health-enhancing PA levels; yet limited intervention studies have examined PA maintenance among Latinas. The present study evaluated the efficacy during the maintenance phase (months 6-12) of the Enhanced PA intervention for Latina adults in Seamos Activas II compared to the Original PA Intervention. Seamos Activas II was conducted in San Diego, California from 2015 to 2020. Underactive adult Latina women (N = 199), mainly of Mexican descent (89%) were randomized to the original intervention or a theory- and technology-enhanced intervention. Their PA was measured objectively (via accelerometers) and via self-report at baseline, 6, and 12 months. Quantile regression models assessed treatment effects on min/week of moderate to vigorous PA (MVPA) at 12 months. Generalized linear models examined treatment effects on indicators of meeting 2008 National PA Guidelines. Both groups maintained the significant gains in MVPA they had made during the first 6 months of the intervention, neither increasing nor decreasing their MVPA over the maintenance period, with no significant between-group differences. At 12 months, 46.3% of Enhanced Intervention participants were meeting self-reported PA guidelines (vs 35.6 % of the Original PA Intervention arm, p = .02). Even with minimal contact throughout the maintenance phase, participants maintained their MVPA, which underscores the importance of continued use of evidence-based behavior change tools and techniques to reinforce newly established habits. Theoretical and technological enhancements may help Latinas to continue meeting PA guidelines during maintenance periods.

Integrating "Exercise Is Medicine" into primary care workflow: a study protocol.

As a major contributor to the burden of most chronic diseases, insufficient physical activity (PA) creates a significant financial burden on the health care system. Numerous interventions effectively increase PA, but few are integrated into primary care clinic workflows. Exercise Is Medicine (EIM) is a global health initiative committed to the belief that PA is integral to the prevention and treatment of diseases and should be routinely assessed as a vital sign and treated in the health care setting. This paper describes an in-progress embedded quality improvement (QI) project that integrates EIM into routine clinical practice. A combination of implementation science (IS) and QI models are used to adapt, implement, and evaluate the integration of EIM into six primary care clinics. The Practical, Robust Implementation and Sustainability Model (PRISM) guided preimplementation evaluation and adaptation of EIM protocol, materials, and delivery strategies. The learning evaluation QI model is used to design, test, refine, and implement EIM using rapid, 3 month Plan-Do-Study-Act microcycles. Learning meetings are used to obtain feedback and optimize workflow. The Stirman Framework is used to document adaptations to the program throughout implementation. Reach, adoption, implementation, effectiveness, and maintenance outcomes embedded within PRISM will guide the program evaluation to determine sustainability and scalability. Using an innovative approach of combining IS and QI methods to improve the identification of primary care patients with insufficient PA to increase their activity levels has great population health potential. Our work will inform the best approaches for EIM integration in primary care.

Design and rationale for a randomized trial of a theory- and technology- enhanced physical activity intervention for Latinas: The Seamos Activas II study.

INTRODUCTION: Latina women report disproportionately high rates of physical inactivity and related chronic health conditions. Physical activity (PA) efforts to date have shown modest success in this at-risk population; thus, more effective interventions are necessary to help Latinas reach national PA guidelines and reduce related health disparities. This paper describes the design, rationale, and baseline findings from the Seamos Activas II intervention. METHODS/DESIGN: The ongoing RCT will test the efficacy of the Seamos Saludables PA print intervention vs. a theory-and technology-enhanced version (Seamos Activas II). The purpose of the study is to increase the percentage of Latinas meeting the national PA guidelines compared to the prior trial, improve biomarkers related to disease, and extend generalizability to a broader and more representative population of Latinas (i.e. Mexican/Mexican-Americans). Intervention refinements included further targeting key constructs of Social Cognitive Theory, and incorporating interactive text message-based self-monitoring strategies. The primary outcome is change in minutes per week of MVPA measured by ActiGraph GT3X+ accelerometers at 6- and 12-months. Secondary PA outcomes assessed by the 7-Day PA Recall will be used to corroborate findings. RESULTS: Participants (N = 199) are Latinas 18-65 years (mean = 43.8) of predominantly Mexican origin (89%). At baseline, objectively measured MVPA was 39.51 min/week (SD = 71.20, median = 10) and self-reported MVPA was 12.47 min/week (SD = 22.54, median = 0).Participants reported generally low self-efficacy and higher cognitive vs. behavioral processes of change. CONCLUSION: Addressing interactivity and accountability through text messaging, and more rigorously targeting theoretical constructs may be key to helping Latinas achieve nationally recommended PA levels and thereby reducing health disparities.

Randomized Trial of a Physical Activity Intervention for Latino Men: Activo.

INTRODUCTION: Latino men experience disproportionately high rates of diseases related to low physical activity, yet they are poorly represented in physical activity intervention trials. Efforts to promote physical activity in Latina women show promising results, yet such interventions are yet to be extended to Latino men. This study tested a computer expert system‒tailored, text messaging-supported physical activity intervention for underactive Spanish-speaking Latino men compared with a control group matched for contact time. Potential predictors of intervention success were also explored. STUDY DESIGN: Randomized trial. Participants were randomized to receive a Tailored Physical Activity Intervention (Intervention) or a Wellness Control (Control). Data were collected in 2015-2017 and analyzed in 2018-2019. SETTING/PARTICIPANTS: Insufficiently active Latino men (n=46). INTERVENTION: Intervention participants received a baseline counseling session and then, individually tailored print materials and text messages on a tapered schedule for 6 months. Control participants received printed wellness materials and text messages on the same schedule. MAIN OUTCOME MEASURES: Primary outcome was a change in weekly moderate to vigorous physical activity from baseline to 6 months measured by accelerometers. Self-reported moderate to vigorous physical activity measured by the 7-day Physical Activity Recall Interview was a secondary outcome. RESULTS: For Intervention participants, median accelerometer-measured moderate to vigorous physical activity increased from 10.0 minutes/week at baseline to 57.5 minutes/week at 6 months, whereas for Control participants, it increased from 21.0 minutes/week at baseline to 23.0 minutes/week at 6 months (p<0.05). Similar results were found for self-reported moderate to vigorous physical activity. At 6 months, 47% of Intervention participants met national guidelines of 150 minutes/week versus 25% of Control participants (p=0.15, not significant). CONCLUSIONS: Findings suggest that an individually tailored intervention can successfully increase moderate to vigorous physical activity in underactive Latino men. Such technology-supported interventions have the potential for broad dissemination. TRIAL REGISTRATION: This study is registered at www.clinicaltrials.gov NCT02512419.

Enhancing engagement in evidence-based tobacco cessation treatment for smokers with mental illness: A pilot randomized trial.

OBJECTIVE: To evaluate the efficacy of a brief telephone-delivered Motivational Interviewing (MI)-based intervention to facilitate engagement in evidence-based cessation treatment for Veterans with mental illness referred to smoking cessation treatment. METHODS: 86 military Veteran smokers with mental illness were recruited from a tobacco cessation consult clinic and randomized to receive either a MI-based treatment engagement intervention (TE; n = 48) or a non-MI assessment and information control (CON; n = 38) condition. Intervention was delivered during a single brief telephone contact. Primary engagement outcomes were 1) attending a treatment session within 30 days and 2) combination treatment (attending session plus using pharmacotherapy). Cessation outcomes included self-reported 24 h cessation attempts and 7 day point abstinence at 3 months post-intervention. Outcomes were assessed at 1 and 3 months post intervention. RESULTS: Outcome analyses included 85 participants (47 TE, 38 CON) using an intent-to-treat analytic approach. Participants were on average 49.5 (13.4) years old, 88% Male, 59% white, 18% African American and 14% Hispanic/Latino(a). Following intervention delivery TE and CON participants did not differ on likelihood of attending a treatment session during the subsequent 30 days (47% vs 45%, respectively). A significant difference was observed when classified as utilizing combination treatment, 40% of TE versus 18% of CON reported use of smoking cessation medication and behavioral counseling (p = 0.04). No statistical differences were observed for cessation outcomes, although more TE than CON participants reported 7 day point abstinence at 3 months post-intervention (30% vs 18%). CONCLUSIONS: The present pilot study provides initial evidence for the feasibility, acceptability and efficacy of a telephone delivered TE intervention for enhancing engagement in combinationevidence evidence-based treatment in a sample of Veteran smokers with mental illness referred to smoking cessation treatment. Smokers with mental illness typically have greater difficulty stopping smoking than those without mental illness. Increased engagement in combination treatment thus has the potential to increase quit rates and ultimately reduce the burden of tobacco use for this population.

Association Between Physical Activity Intervention Website Use and Physical Activity Levels Among Spanish-Speaking Latinas: Randomized Controlled Trial.

BACKGROUND: The internet's low cost and potential for high reach makes Web-based channels prime for delivering evidence-based physical activity (PA) interventions. Despite the well-studied success of internet-based PA interventions in primarily non-Hispanic white populations, evidence on Spanish-speaking Latinas' use of such interventions is lacking. The recent rise in technology use among Latinas in the United States, a population at heightened risk for low PA levels and related conditions, suggests that they may benefit from Web-based PA interventions tailored to their cultural and language preferences. OBJECTIVE: The goal of the research was to examine participant engagement with various features of an internet-based PA intervention for Latinas and explore how use of these features was differentially associated with adoption and maintenance of PA behavior change. METHOD: Pasos Hacia la Salud tested a Spanish-language, culturally adapted, individually tailored, internet-based PA intervention versus a Spanish language, internet-based, Wellness Contact Control condition for underactive Latinas (N=205, mean age 39.2 [SD 10.5] years, 84% Mexican American). These analyses examined engagement with the website and explored how use was associated with adoption and maintenance of moderate to vigorous physical activity (MVPA) behavior. RESULTS: Overall, participants logged on to the website an average of 22 times (SD 28) over 12 months, with intervention participants logging on significantly more than controls (29 vs 14.7, P<.001). On average, participants spent more time on the website at months 1, 4, and 6 compared to all other months, with maximum use at month 4. Both log-ins and time spent on the website were significantly related to intervention success (achieving higher mean minutes of MVPA per week at follow-up: b=.48, SE 0.20, P=.02 for objectively measured MVPA and b=.74, SE 0.34, P=.03 for self-reported MVPA at 12 months, controlling for baseline). Furthermore, those meeting guidelines by the Centers for Disease Control and Prevention for PA at 12 months (≥150 minutes per week of MVPA) logged on significantly more than those not meeting guidelines (35 vs 20 over 12 months, P=.002). Among participants in the intervention arm, goal-setting features, personal PA reports, and PA tips were the most used portions of the website. Higher use of these features was associated with greater success in the program (significantly more minutes of self-reported MVPA at 12 months controlling for baseline). Specifically, one additional use of these features per month over 12 months translated into an additional 34 minutes per week of MVPA (goals feature), 12 minutes per week (PA tips), and 42 minutes per week (PA reports). CONCLUSIONS: These results demonstrate that greater use of a tailored, Web-based PA intervention, particularly certain features on the site, was significantly related to increased PA levels in Latinas. TRIAL REGISTRATION: ClinicalTrials.gov NCT01834287; https://clinicaltrials.gov/ct2/show/NCT01834287.

Prevention of Lower Urinary Tract Symptoms Research Consortium Focus Group Study of Habits, Attitudes, Realities, and Experiences of Bladder Health.

AIM: The study purpose is to explore adolescent and adult women's experiences, perceptions, beliefs, knowledge and behaviors related to bladder health across the life course using a socioecological perspective. Lower urinary tract symptoms affect between 20-40% of young adult to middle-aged women, with symptoms increasing in incidence and severity with aging. There is limited evidence to address bladder health promotion and prevention of dysfunction. This first study of the Prevention of Lower Urinary Tract Symptoms (PLUS) Research Consortium is designed to address gaps in existing qualitative research in this area. DESIGN: This focus group study will be implemented across seven geographically diverse United States research centers using a semi-structured focus group guide informed by a conceptual framework based on the socioecological model. METHODS: The study was approved in July 2017. A total of 44 focus groups composed of 6-8 participants representing six different age categories (ranging from 11 to over 65 years) will be completed. We aim to recruit participants with diverse demographic and personal characteristics including race, ethnicity, education, socioeconomic status, urban/rural residence, physical/health conditions and urinary symptom experience. Up to 10 of these focus groups will be conducted in Spanish. Focus group transcripts will undergo content analysis and data interpretation to identify and classify themes and articulate emerging themes. DISCUSSION: This foundational qualitative study seeks to develop an evidence base to inform future research on bladder health promotion in adolescent and adult women. IMPACT: This study has the potential to provide new insights and understanding into adolescent and adult women's lived experience of bladder health, the experience of lower urinary symptoms and knowledge and beliefs across the life course. This article is protected by copyright. All rights reserved.

The Go-VAR (Veterans Active Recovery): An Adjunctive, Exercise-Based Intervention for Veterans Recovering from Substance Use Disorders.

Substance use disorders (SUD) are prevalent among veterans, and the relapse rate is estimated at ≥60% within one year of treatment. Exercise's broad health benefits make it an appealing adjunctive component to interventions preventing relapse among individuals with SUDs. After conducting formative research, we designed and conducted the Go-VAR! (Veterans Active Recovery) pilot study to examine the feasibility and acceptability of a multi-component exercise-based intervention for veterans seeking SUD treatment through the outpatient Alcohol & Drug Treatment Program (ADTP) at the VA San Diego Healthcare System (VASDHS). Participants (N = 15; mean age = 45 [SD = 9.7]; 13% Hispanic, 60% White) from the La Jolla VASDHS outpatient ADTP were enrolled in this 12-week one-arm pilot study. Feasibility and acceptability were established: 70% of participants attended weekly psychoeducation groups, wore their Fitbit Charge HR, increased their weekly physical activity, and used their study-provided YMCA memberships, group exercise training sessions, and Fit4Me personal training program. Lower use of both alcohol and drugs were reported at the end of the study (p < .0001). Significant increases in daily steps as measured by the Fitbit HR and improvements in measures of physical fitness were also achieved (p < .05). Future work should focus on potential integration within the VA system.

Adapting Technological Interventions to Meet the Needs of Priority Populations.

Cardiovascular diseases (CVD) comprise the leading cause of mortality worldwide, accounting for 3 in 10 deaths. Individuals with certain risk factors, including tobacco use, obesity, low levels of physical activity, type 2 diabetes mellitus, racial/ethnic minority status and low socioeconomic status, experience higher rates of CVD and are, therefore, considered priority populations. Technological devices such as computers and smartphones are now routinely utilized in research studies aiming to prevent CVD and its risk factors, and they are also rampant in the public and private health sectors. Traditional health behavior interventions targeting these risk factors have been adapted for technology-based approaches. This review provides an overview of technology-based interventions conducted in these priority populations as well as the challenges and gaps to be addressed in future research. Researchers currently possess tremendous opportunities to engage in technology-based implementation and dissemination science to help spread evidence-based programs focusing on CVD risk factors in these and other priority populations.

Integrating Physical Activity in Primary Care Practice.

Based on a collaborative symposium in 2014 hosted by the Society of Behavioral Medicine (SBM) and the American College of Sports Medicine (ACSM), this paper presents a model for physical activity counseling for primary care physicians (PCPs). Most US adults do not meet national recommendations for physical activity levels. Socioecological factors drive differences in physical activity levels by geography, sex, age, and racial/ethnic group. The recent Patient Protection and Affordable Care Act incentivizes PCPs to offer patients physical activity counseling. However, PCPs have reported socioecological barriers to physical activity counseling and also patient barriers to physical activity, spanning from the individual to the environmental (eg, lack of safe spaces for physical activity), policy (eg, reimbursement policies), and organizational (eg, electronic medical record protocols, worksite norms/policies) levels. The aims of this paper are to: 1) discuss barriers to PCP counseling for physical activity; 2) provide evidence-based strategies and techniques to help PCPs address these counseling barriers; and 3) suggest practical steps for PCPs to counsel patients on physical activity using strategies and supports from policy, the primary care team, and other support networks.

Using interactive Internet technology to promote physical activity in Latinas: Rationale, design, and baseline findings of Pasos Hacia La Salud.

Internet-based interventions show promise as an effective channel for promoting physical activity. However, a paucity of research has been conducted among underserved groups despite recent increases in Internet access and physical activity-related health disparities in these communities. Thus, the current randomized controlled trial will test the efficacy of an individually tailored, Internet-based physical activity intervention for Latinas. This program was culturally and linguistically adapted for the target population through extensive formative research. Two hundred eighteen sedentary Latinas were randomly assigned to the Tailored Physical Activity Internet Intervention or the Wellness Contact Control Internet Group. The Physical Activity Internet Intervention, based on Social Cognitive Theory and the Transtheoretical Model, utilizes a website with features including self-monitoring, goal setting, discussion forum, links to online resources, individually tailored and motivation-matched physical activity feedback reports, and exercise tip sheets. Participants receive regular emails over the first 6months with a tapered dose during the second 6months (maintenance phase) to alert them to new content on the website. The main outcome is differences in minutes/week of moderate to vigorous physical activity at six months as measured by the 7-Day Physical Activity Recall and accelerometer data. High reach, low cost, culturally relevant Internet-based interventions that encourage physical activity among Latinas could help reduce health disparities and thus have a substantial positive impact on public health.

An Exercise-Based Program for Veterans with Substance Use Disorders: Formative Research.

Substance use disorders (SUDs) are prevalent among veteran populations. Adjunctive treatments for SUDs are warranted for many reasons, including high relapse rates. Physical exercise has broad health benefits as well as mood-enhancing, anxiolytic, and withdrawal-reducing effects, but veterans with SUDs report low rates of regular exercise. Evaluating exercise-based interventions that incorporate evidence-based behavior change strategies tailored to meet the unique needs of veterans with SUDs is warranted. This article describes the formative research conducted to evaluate the following information among veterans receiving treatment for SUDs: (1) interest in an adjunctive exercise program to supplement their current SUD treatment; and (2) exercise program design considerations. A survey and small group interviews were conducted to obtain both quantitative and qualitative data. Results suggested that veterans with SUDs are interested in exercise, and participants provided perceptive suggestions for modifying an existing evidence-based program. These findings will be used to design an exercise-based treatment program tailored specifically for veterans with SUDs.

Predicting use of assistance when quitting: a longitudinal study of the role of quitting beliefs.

BACKGROUND: A growing literature addresses the need to reduce cigarette smoking prevalence by increasing the use of assistance when quitting. A key focus is to identify strategies for enhancing adoption of effective interventions in order to increase utilization of evidence-based treatments. PURPOSE: To examine the effect of beliefs regarding ability to quit on utilization of assistance for smoking cessation. A mediation model was hypothesized whereby the relationship between smoking and use of assistance is influenced by beliefs in ability to quit. METHODS: The present study includes 474 of 1000 respondents to baseline and follow-up California Smokers Cohort surveys conducted from 2011 to 2013. Included were baseline smokers who reported a 24-h quit attempt at follow-up. Baseline variables were used to predict use of assistance when quitting. RESULTS: The hypothesized model was tested using a product of coefficients method, controlling for demographics. Greater heaviness of smoking and lower belief in ability to quit were significantly related to use of assistance. Quitting beliefs significantly mediated the relationship between nicotine dependence and use of assistance. CONCLUSIONS: The present data support a mechanism whereby the effect of smoking rate on treatment utilization is mediated by beliefs in ability to quit. Greater belief in one's ability to quit may represent an obstacle to treatment utilization by reducing the likelihood of successful cessation. The present findings suggest the value of targeted messages from health care providers that normalize the need for assistance when attempting to change an addictive behavior and emphasize the difficulty of quitting without assistance.

Exercise-based treatments for substance use disorders: evidence, theory, and practicality.

BACKGROUND: Epidemiological studies reveal that individuals who report risky substance use are generally less likely to meet physical activity guidelines (with the exception of certain population segments, such as adolescents and athletes). A growing body of evidence suggests that individuals with substance use disorders (SUDs) are interested in exercising and that they may derive benefits from regular exercise, in terms of both general health/fitness and SUD recovery. OBJECTIVES: The aims of this paper were to: (i) summarize the research examining the effects of exercise-based treatments for SUDs; (ii) discuss the theoretical mechanisms and practical reasons for investigating this topic; (iii) identify the outstanding relevant research questions that warrant further inquiry; and (iv) describe potential implications for practice. METHODS: The following databases were searched for peer-reviewed original and review papers on the topic of substance use and exercise: PubMed Central, MEDLINE, EMBASE, PsycINFO, and CINAHL Plus. Reference lists of these publications were subsequently searched for any missed but relevant manuscripts. Identified papers were reviewed and summarized by both authors. RESULTS: The limited research conducted suggests that exercise may be an effective adjunctive treatment for SUDs. In contrast to the scarce intervention trials to date, a relative abundance of literature on the theoretical and practical reasons supporting the investigation of this topic has been published. CONCLUSIONS: Definitive conclusions are difficult to draw due to diverse study protocols and low adherence to exercise programs, among other problems. Despite the currently limited and inconsistent evidence, numerous theoretical and practical reasons support exercise-based treatments for SUDs, including psychological, behavioral, neurobiological, nearly universal safety profile, and overall positive health effects.

The association between family and friend integration and physical activity: results from the NHIS.

BACKGROUND: Social integration predicts morbidity and mortality, but its relationships with specific health behaviors that could explain this relationship, such as physical activity, have not been established. Additionally, studies associating social integration with health have not distinguished between sources of social contact (family vs. friends), which could be differentially related to health. PURPOSE: The purpose of this study was to examine the association between social integration and physical activity and to explore differences in family and friend social integration. METHOD: Data came from the 2001 wave of the National Health Interview Survey. Adult participants (N = 33,326) indicated levels of social integration by reporting whether they had seen and/or called friends and/or family in the past 2 weeks and also reported their weekly minutes of physical activity. Logistic regression was used to determine odds of meeting physical activity (PA) guidelines (≥ 150 min/week) and odds of inactivity (0 min/week) based on levels of social integration. RESULTS: Greater integration predicted higher odds of meeting PA guidelines and lower odds of inactivity after controlling for sociodemographic variables. This association was stronger and dose-dependent for integration with friends, whereas moderate family contact predicted greater activity than high levels of family contact. CONCLUSION: Those who are more socially integrated, particularly with friends rather than family, are also more physically active, which could partially explain the link between social integration and morbidity and mortality. Future studies examining this association should distinguish between sources of integration and explore why and how contact with friends vs. family is differentially associated with health behaviors.

A meta-analysis of mental health treatments and cardiac rehabilitation for improving clinical outcomes and depression among patients with coronary heart disease.

OBJECTIVE: To quantify the efficacy of mental health (antidepressants & psychotherapies) and cardiac rehabilitation treatments for improving secondary event risk and depression among patients with coronary heart disease (CHD). METHODS: Using meta-analytic methods, we evaluated mental health and cardiac rehabilitation therapies for a) reducing secondary events and 2) improving depression severity in patients with CHD. Key word searches of PubMed and Psychlit databases and previous reviews identified relevant trials. RESULTS: Eighteen mental health trials evaluated secondary events and 22 trials evaluated depression reduction. Cardiac rehabilitation trials for the same categories numbered 17 and 13, respectively. Mental health treatments did not reduce total mortality (absolute risk reduction [ARR] = -0.001, confidence interval [95% CI] = -0.016 to 0.015; number needed to treat [NNT] = ∞), showed moderate efficacy for reducing CHD events (ARR = 0.029, 95% CI = 0.007 to 0.051; NNT = 34), and a medium effect size for improving depression (Cohen d = 0.297). Cardiac rehabilitation showed similar efficacy for treating depression (d = 0.23) and reducing CHD events (ARR = 0.017, 95% CI = 0.007 to 0.026; NNT = 59) and reduced total mortality (ARR = 0.016, 95% CI = 0.005 to 0.027; NNT = 63). CONCLUSIONS: Among patients with CHD, mental health treatments and cardiac rehabilitation may each reduce depression and CHD events, whereas cardiac rehabilitation is superior for reducing total mortality risk. The results support a continued role for mental health treatments and a larger role for mental health professionals in cardiac rehabilitation.