Nothing About Us Without Us: Involving Youth Living With HIV in a Virtual Advisory Board.

PURPOSE: We adapted a traditional community advisory board to the needs of youth living with HIV (YLWH), resulting in a virtual, asynchronous, and anonymous youth advisory board (YAB). The YAB's evolution fostered participation during the adaptation of an HIV care mobile health application. METHODS: YAB members, comprised of YLWH in South Texas, engaged in the mobile application's formative evaluation, adaptation, and pilot implementation. We collected feedback via surveys and interviews, analyzed and integrated responses, tracked participation and YAB adaptations, and performed content analysis. RESULTS: Driven by feedback, the YAB evolved from in-person group meetings to the current iteration. We administered five surveys, and YAB members provided feedback on communication preferences; mobile app elements; privacy and confidentiality; and virtual support groups. DISCUSSION: Our adaptive process highlights three primary drivers of innovation: COVID-19 risk reduction, asynchrony, anonymity. Our success in maintaining YAB engagement suggests the adapted model could be employed to support youth input in other contexts.

#BingeDrinking-Using Social Media to Understand College Binge Drinking: Qualitative Study.

BACKGROUND: Hazardous drinking among college students persists, despite ongoing university alcohol education and alcohol intervention programs. College students often post comments or pictures of drinking episodes on social media platforms. OBJECTIVE: This study aimed to understand one university's student attitudes toward alcohol use by examining student posts about drinking on social media platforms and to identify opportunities to reduce alcohol-related harm and inform novel alcohol interventions. METHODS: We analyzed social media posts from 7 social media platforms using qualitative inductive coding based on grounded theory to identify the contexts of student drinking and the attitudes and behaviors of students and peers during drinking episodes. We reviewed publicly available social media posts that referenced alcohol, collaborating with undergraduate students to select their most used platforms and develop locally relevant search terms; all posts in our data set were generated by students associated with a specific university. From the codes, we derived themes about student culture regarding alcohol use. RESULTS: In total, 1151 social media posts were included in this study. These included 809 Twitter tweets, 113 Instagram posts, 100 Greekrank posts, 64 Reddit posts, 34 College Confidential posts, 23 Facebook posts, and 8 YouTube posts. Posts included both implicit and explicit portrayals of alcohol use. Across all types of posts reviewed, positive drinking attitudes were most common, followed by negative and then neutral attitudes, but valence varied by platform. Posts that portrayed drinking positively received positive peer feedback and indicate that drinking is viewed by students as an essential and positive part of university student culture. CONCLUSIONS: Social media provide a real-time picture of students' behavior during their own and others' heavy drinking. Posts portray heavy drinking as a normal part of student culture, reinforced by peers' positive feedback on posts. Interventions for college drinking should help students manage alcohol intake in real time, provide safety information during alcohol use episodes, and raise student awareness of web-based privacy concerns and reputation management. Additional interventions for students, alumni, and parents are needed to address positive attitudes about and traditions of drinking.

Think-Aloud Testing of a Novel Safer Drinking App for College Students During COVID-19: Usability Study.

BACKGROUND: Hazardous alcohol consumption, and binge drinking in particular, continues to be common among college students, posing the greatest risk for their health and safety. Despite widespread exposure to evidence-based preventive interventions among US undergraduates, only modest and temporary effects on risky drinking occur. Formative studies have demonstrated that students want a more engaging intervention tool for risky drinking that can be used just in time. OBJECTIVE: The purpose of this study is to test the appeal, relevance, and perceived utility of a draft mobile app for safer student drinking at a public university in Virginia. METHODS: Undergraduate student participants tested the draft mobile app via a web-based prototype that tailors to individual feedback with hot spots that responded to their taps to mimic app functionality. They narrated their impressions, navigation, and comments in a standardized think-aloud procedure. After each round of think-aloud interviews, researchers debriefed the investigators and developers to discuss findings and brainstorm app modifications. RESULTS: Minor changes to the functionality and aesthetics would improve usability of the app (eg, option for light mode in app settings). Student testers recommended tailoring the app to the needs of college students and to aspects of the local university's drinking culture. CONCLUSIONS: Findings from this study will be synthesized with information gained from other formative work to determine the final app features. We will test the app in a pilot randomized trial to assess app use and the impact of the app on college student drinking behavior over several months.

Including partners in discussions of sexual side effects from breast cancer: a qualitative study of survivors, partners, and providers.

PURPOSE: Ensuring there are clear standards for addressing cancer-related sexual side effects is important. Currently, there are differences in two leading sets of clinical guidelines regarding the inclusion of survivors' romantic partners into clinical discussions between survivors and their providers about this issue. To help refine guidelines, we examine breast cancer survivor, partner, and oncology provider perspectives about including partners in discussions about cancer-related sexual side effects in a secondary analysis of a broader qualitative study. METHODS: Partnered female breast cancer survivors (N = 29) completed online surveys, and intimate partners of breast cancer survivors (N = 12) and breast oncology providers (N = 8) completed semi-structured interviews. Themes were derived from thematic content analysis. RESULTS: Among survivors who reported a discussion with their provider, fewer than half indicated their partner had been present, despite most survivors expressing it was - or would have been - helpful to include their partner. Partners also largely indicated being included was or would have been helpful, when welcomed by the survivor. Providers similarly emphasized the importance of survivors' autonomy in deciding whether to discuss sexual concerns in the presence of a partner. CONCLUSIONS: Partners were infrequently included in conversations about cancer-related sexual side effects, even though survivors, partners, and providers alike expressed value in these discussions occurring with the couple together - when that is the survivor's preference. Findings suggest future clinical guidelines should emphasize that incorporating partners into clinical discussions about sexual concerns is important for many breast cancer patients. Soliciting and enacting patients' preferences is essential for truly patient-centered care.

South African university women's perspectives on intimate partner violence: a qualitative study of reactions to a tailored vignette.

Intimate partner violence is an ongoing issue in South Africa, which has the highest rates of violence against women and girls in the world. Intimate partner violence is common in Limpopo, where women, including university students, experience elevated rates of violent crime. This qualitative study was conducted to examine university students' perspectives regarding intimate partner violence among their peers. A culturally tailored vignette was used to prompt reflection from 38 female university students in Limpopo. Audiotaped responses to the vignette were transcribed, coded and analysed using thematic analysis. Four main themes were developed from participants' responses to the vignette: cultural beliefs, the university's role in intimate partner violence, likely outcomes of intimate partner violence, and future interventions. Intimate partner violence was seen as a common problem within the university. Students' responses indicated that cultural beliefs perpetuated violence against women, with women entering and remaining in abusive relationships for financial security or resources such as housing. Students also reported lack of adequate on-campus housing options, limited knowledge of intimate partner violence, and few actions to reduce intimate partner violence, all of which placed then at heightened risk of intimate partner violence.

Pilot Randomized Controlled Trial of Motivational Interviewing with Sexual Minority Male Couples to Reduce Drug Use and Sexual Risk: The Couples Health Project.

A randomized controlled trial evaluated the preliminary efficacy of a dyadically-delivered motivational interviewing (MI) intervention to reduce drug use and sexual risk in a sample of 50 sexual minority (cis)male (SMM) couples. In each couple, at least one partner was aged 18-29; reported drug use and sexual HIV transmission risk; and was HIV-negative. Couples were randomized to either the three-session MI intervention or an attention-matched control, with follow-up surveys completed at 3- and 6-months post-baseline. Between-group differences for all outcomes were non-significant in the overall sample. Subsequent moderation analyses indicated the intervention significantly reduced illicit drug use (excluding marijuana) at 3-month follow-up when either respondents (B = - 1.96; interval rate ratio-IRR 0.02-1.22; p = .001), their partners (B = - 2.60; IRR 0.01-0.64; p = .004), or both (B = - 2.38; IRR 0.01-0.80; p = .001) reported high levels of baseline use. The intervention also reduced condomless anal sex (CAS) with casual partners when both partners reported high frequency baseline CAS (B = - 2.54; IRR 0.01-0.83; p = .047). Findings provide initial evidence of the potential for MI to address drug use and sexual risk-taking among SMM couples at highest risk.Trial Registration ClinicalTrials.gov (NIH U.S. National Library of Medicine) Identifier: #NCT03386110.

Development of Motivational Interviewing Treatment Integrity (MITI) Fidelity Codes Assessing Motivational Interviewing with Couples.

This study evaluated preliminary reliability and validity evidence for novel scores that extend the motivational interviewing treatment integrity (MITI) coding system to assess elements unique to motivational interviewing (MI) with couples. We recruited 20 cismale couples where at least one partner was aged 18-29; reported substance use; and was HIV-negative. Couples were randomized to a three-session MI or attention-matched education control. Four coders rated audio-recordings of initial sessions in both conditions. Novel global scores had high nearly-exact percent agreement (Decreasing Dyadic Ambivalence = 100%; Facilitating Dyadic Functioning = 94%). Consistency for novel behavior counts was good (ICCdyadic reflections = .72) and above minimum thresholds (nearly-exact agreement for Relationship Affirmations = 78%). MI sessions generated novel and established MITI codes that were significantly better than education sessions, providing preliminary evidence of validity. Findings provided initial support for the use of these novel scores in future research evaluating MI-based substance use and HIV risk reduction studies with couples.

Effects of an Internet-Based Cognitive Behavioral Therapy for Insomnia Program on Work Productivity: A Secondary Analysis.

BACKGROUND: Cognitive-behavioral therapy for insomnia (CBT-I) may improve productivity along with insomnia symptoms, but the long-term duration of productivity gains is unknown. PURPOSE: In this secondary analysis, effects of Internet-delivered CBT-I on work-related and daily activity productivity were examined through 1 year post-treatment. METHODS: Adults with chronic insomnia (N = 303) were randomized to Internet-delivered CBT-I (Sleep Healthy Using the Internet [SHUTi]) or to patient education (PE). Participants reported interference with attendance (absenteeism) and productivity (presenteeism) at paid employment and in daily activities outside work on the Work Productivity Activity Impairment scale at baseline, 9 weeks later for postintervention assessment (post-assessment), and 6- and 12-month follow-ups. RESULTS: Participants randomized to SHUTi were about 50% less likely than those in the PE condition to report any absenteeism (logistic regression odds ratio [OR] = 0.48 [95% confidence intervals {CI} = 0.24,0.96]), total impairment (OR = 0.52 [95% CI = 0.29,0.93]), or activity impairment (OR = 0.50 [95% CI = 0.30,0.85]) at post-assessment; however, differences were not detected at 6- or 12-month follow-ups. SHUTi participants also reported lower overall levels of presenteeism (constrained longitudinal data analysis MDiff = -6.84 [95% CI = -11.53, -2.15]), total impairment (MDiff = -7.62 [95% CI = -12.50, -2.73]), and activity impairment (MDiff = -7.47 [95% CI = -12.68, -2.26]) at post-assessment relative to PE participants. Differences were sustained at 6-month follow-up for presenteeism (MDiff = -5.02 [95% CI = -9.94, -0.10]) and total impairment (MDiff = -5.78 [95% CI = -10.91, -0.65]). No differences were detected by 12-month follow-up. CONCLUSIONS: Findings suggest that Internet-based CBT-I may help accelerate improvement in work-related and daily activity impairment corroborating prior research, but did not find that CBT-I has persistent, long-term benefits in productivity relative to basic insomnia education. TRIAL REGISTRATION: NCT00328250 "Effectiveness of Internet Cognitive Behavioral Therapy Intervention for Treating Insomnia" (https://clinicaltrials.gov/ct2/show/NCT00328250).

Motivational interviewing with male couples to reduce substance use and HIV risk: Manifestations of partner discord and strategies for facilitating dyadic functioning.

The efficacy of motivational interviewing (MI) to reduce substance use is well established; however, its use with couples has met with mixed results. The development of such interventions is particularly relevant for male couples, as rates of substance use in this population are comparatively high and use is associated with aspects of sexual relationship functioning. One challenge noted in conducting MI with couples is how to respond to situations in which partners disagree with one another or argue against change. Guided by the couples interdependence theory, we conceptualized conflicts within session as failures in the accommodation process. We used qualitative analysis to examine manifestations of conflict in session and to identify effective provider response strategies. The sample included 14 cis-male couples with at least 1 partner was aged 18-29 years, reported substance use, and was HIV negative. All couples completed 3 MI sessions lasting 60-75 min each. Manifestations of conflict included conflation of thoughts/feelings, vague or indirect communication, and inaccurate assumptions. Effective provider responses included correcting assumptions, shifting focus, relationship repair, "common ground" reflections, and relationship affirmations. Observed conflicts aligned with conceptualizations of destructive resolutions to the accommodation process (i.e., exit and neglect). Effective provider responses to conflict facilitated dyadic functioning and catalyzed constructive accommodation. These results provide an initial compendium of provider skills and strategies that may be particularly relevant in work with sexual minority male couples, for whom achieving accommodation around drug use and sexual health goals is often viewed as a key mechanism of intervention. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Do treatment effects of a web-based cognitive behavioral therapy for insomnia intervention differ for users with and without pain interference? A secondary data analysis.

Cognitive-behavioral therapy for insomnia (CBT-I) shows treatment benefits among individuals with pain interference; however, effects of Internet-delivered CBT-I for this population are unknown. This secondary analysis used randomized clinical trial data from adults assigned to Internet-delivered CBT-I to compare changes in sleep by pre-intervention pain interference. Participants (N = 151) completed the Insomnia Severity Index (ISI) and sleep diaries [sleep onset latency (SOL); wake after sleep onset (WASO)] at baseline, post-assessment, 6- and 12-month follow-ups. Linear mixed-effects models showed no differences between pain interference groups (no, some, moderate/severe) for changes from baseline to any follow-up timepoint for ISI (p = .72) or WASO (p = .88). There was a small difference in SOL between those reporting some versus no or moderate/severe pain interference (p = .04). Predominantly comparable and sustained treatment benefits for both those with and without pain interference suggest that Internet-delivered CBT-I is promising for delivering accessible care to individuals with comorbid pain and insomnia.

A secondary analysis of the role of geography in engagement and outcomes in a clinical trial of an efficacious Internet intervention for insomnia.

BACKGROUND: Online interventions for insomnia can increase access to treatments for those with limited access to services. What remains unknown is whether individuals from more isolated (vs. more densely populated) regions engage with, and benefit as much from, an online intervention. This secondary analysis examined the relationship of geographical indices with engagement and outcomes of an efficacious, fully automated online cognitive behavioral therapy for insomnia (CBT-I) program (Sleep Healthy Using the Internet-SHUTi). METHOD: 303 participants (M age  = 43.3; SD = 11.6) were randomly assigned to SHUTi or an online patient education condition and assessed at baseline and post intervention. Rural code of participants was determined using participant zip codes. Distance to the nearest sleep medicine provider was calculated as the distance between the center of the nearest provider's city (from a publicly available list of CBT-I providers) and the center of the participants' zip code. Adherence outcomes were number of intervention core completions, sleep diaries, and logins. Sleep outcomes were insomnia severity as well as sleep onset latency and wake after sleep onset derived from online sleep diaries. RESULTS: Individuals were from a range of geographic locations. Most lived in fairly densely populated areas; however, there was a large variation in distance to the nearest sleep medicine provider. Findings indicate that the efficacy, adherence, and engagement with SHUTi were not impacted by where people lived. Controlling for age and gender did not impact any of the relationships among geography variables (i.e., distance, ruralness) and adherence or sleep related outcomes. CONCLUSIONS: Internet interventions must demonstrate that they can overcome obstacles posed by geography. This is the first study to examine the geographic location of participants and its association with engagement with, and outcomes of, online CBT-I.

Year 2 of Affordable Care Act Qualified Health Plans (QHPs) in a Medicaid Nonexpansion State: QHPs Associated With Viral Suppression for Virginia AIDS Drug Assistance Program Clients.

BACKGROUND: For year 1 of the Affordable Care Act (ACA), Virginia AIDS Drug Assistance Program (ADAP) clients with Qualified Health Plans (QHPs) achieved a higher rate of viral suppression. This study characterizes the demographic and health care delivery factors associated with QHP enrollment in year 2 and assesses the relationship between 2015 QHP coverage and HIV viral suppression. METHODS: The cohort included Virginia ADAP clients who were eligible for ADAP-funded QHPs. Data were collected from 2014 to 2015. Multivariable binary logistic regression was conducted to assess the association of demographic and health care delivery factors with QHP enrollment and viral suppression. RESULTS: In year 2, 63% of the cohort (n = 4631) enrolled in QHPs; 2015 ADAP-funded QHP enrollment was associated with 2014 ADAP-funded QHP (adjusted odds ratio [aOR], 111.11; 95% confidence interval [CI], 90.91-166.67), 2014 engagement in care (aOR, 2.16; 95% CI, 1.65-2.82), age (P < .001), race/ethnicity (P = .03), financial status (P < .001), and region (P < .001). For clients engaged in care (n = 2501), viral suppression was higher (83.3%) for those with ADAP-funded QHP coverage than for those who received medications from ADAP (79.9%). In multivariable binary logistic regression, achieving viral suppression was associated with 2015 QHP coverage (aOR, 1.27; 95% CI, 1.01-1.60), an initially undetectable viral load (aOR, 2.69; 95% CI, 2.13-3.39), gender (P = .03), age (P = .01), no AIDS diagnosis (aOR, 1.41; 95% CI, 1.12-1.78), financial status (P = .004), and region (P < .001). CONCLUSIONS: Virginia ADAP client 2015 QHP enrollment increased compared with year 1 and varied based on demographic and health care delivery factors. QHP coverage was again associated with viral suppression, an essential outcome for individuals and for public health.

Cognitive mechanisms of sleep outcomes in a randomized clinical trial of internet-based cognitive behavioral therapy for insomnia.

OBJECTIVE: The aim of this study was to investigate in a randomized clinical trial the role of sleep-related cognitive variables in the long-term efficacy of an online, fully automated cognitive behavioral therapy intervention for insomnia (CBT-I) (Sleep Healthy Using the Internet [SHUTi]). METHOD: Three hundred and three participants (Mage = 43.3 years; SD = 11.6) were randomly assigned to SHUTi or an online patient education condition and assessed at baseline, postintervention (nine weeks after baseline), and six and 12 months after the intervention period. Cognitive variables were self-reported internal and chance sleep locus of control, dysfunctional beliefs and attitudes about sleep (DBAS), sleep specific self-efficacy, and insomnia knowledge. Primary outcomes were self-reported online ratings of insomnia severity (Insomnia Severity Index), and sleep onset latency and wake after sleep onset from online sleep diaries, collected 12 months after the intervention period. RESULTS: Those who received SHUTi had, at postassessment, higher levels of insomnia knowledge (95% confidence interval [CI] = 0.10-0.16) and internal sleep locus of control (95% CI = 0.04-0.55) as well as lower DBAS (95% CI = 1.52-2.39) and sleep locus of control attributed to chance (95% CI = 0.15-0.71). Insomnia knowledge, chance sleep locus of control, and DBAS mediated the relationship between condition and at least one 12-month postassessment sleep outcome. Within the SHUTi condition, changes in each cognitive variable (with the exception of internal sleep locus of control) predicted improvement in at least one sleep outcome one year later. CONCLUSION: Online CBT-I may reduce the enormous public health burden of insomnia by changing underlying cognitive variables that lead to long-term changes in sleep outcomes.

Development and differentiability of three brief interventions for risky alcohol use that include varying doses of motivational interviewing.

BACKGROUND: While brief intervention (BI) for risky alcohol use generally yields positive effects among those identified by screening, effect sizes are small and there is unexplained heterogeneity in outcome. The heterogeneity may be related to differences in intervention style and content, including elements of motivational interviewing (MI). To date, it has been difficult to interpret the role of MI in BI and these gaps in knowledge interfere with efforts to train, disseminate and implement BI that retains and maximizes efficacy. This study sought to develop BI protocols with varying doses of MI and test their differentiability. Differentiable BI protocols could allow for future studies that prospectively evaluate the role MI plays in affecting BI outcome. METHODS: We developed three intervention protocols: brief advice, standard BI (NIAAA Clinician's Guide), and MI-enhanced BI and administered them to 45 primary care patients who reported exceeding recommended drinking limits. We then rated the BI sessions for fidelity to the assigned protocol as well as MI consistency based on Motivational Interviewing Treatment Integrity (MITI) scale scores. The differentiability of BI protocols was determined by calculating fidelity to assigned protocols and comparing MITI scores using pairwise, Tukey-adjusted comparisons of least squares mean scores. RESULTS: High rates of fidelity to each protocol were achieved. The three BI protocols were also highly differentiable based on MITI scores. CONCLUSIONS: The three interventions can be used in future trials to prospectively examine the role MI has in determining BI outcome. Trial registration clinicaltrials.gov NCT02978027, retrospectively registered 11/28/16.

Informal Caregivers' Use of Internet-Based Health Resources: An Analysis of the Health Information National Trends Survey.

BACKGROUND: Informal caregivers express strong interest in technology innovations to help them in their caregiving role; however, divides across sociodemographic characteristics in internet and technology access may preclude the most vulnerable caregivers from accessing such resources. OBJECTIVE: This study aims to examine caregivers' internet use, both generally and for seeking health-related information, and whether usage differs as a function of caregivers' characteristics. METHODS: Data were analyzed from the Health Information National Trends Survey 5 Cycle 1. Participants were included in analyses if they self-identified as providing uncompensated care to a close individual. Caregivers reported internet use factors, age, education, rurality, general health, distress, and objective caregiving burden. We used chi-square tests of independence with jackknife variance estimation to compare whether internet use factors differed by caregivers' characteristics. RESULTS: A total of 77.5% (303/391) caregivers surveyed reported ever using the internet. Of internet users, 88.1% (267/303) accessed from a home computer and 83.2% (252/303) from a mobile device. Most caregivers accessed health information for themselves (286/391, 73.1%) or others (264/391, 67.5%); fewer communicated with a doctor over the Web (148/391, 37.9%) or had a wellness app (171/391, 43.7%). Caregivers reporting younger age, more education, and good health were more likely to endorse any of these activities. Furthermore, two-thirds of caregivers (258/391, 66.0%) endorsed trust in health information from the internet. CONCLUSIONS: Computers and mobile devices are practical platforms for disseminating caregiving-related information and supportive services to informal caregivers; these modalities may, however, have a more limited reach to caregivers who are older, have less education, and are in poorer health.

Development and Initial Validation of the Assessment of Motivational Interviewing Groups - Observer Scales (AMIGOS).

This article documents the development and initial validation of a global observer instrument, the Assessment of Motivational Interviewing Groups - Observer Scales (AMIGOS). The AMIGOS includes three scales composed of 18 items documenting group processes, client-centered style, and motivational interviewing (MI) change focus. Three experienced coders independently rated 18 sessions of various group approaches. The AMIGOS showed high inter-rater intraclass correlation coefficient (ICC) and Cronbach's alpha, strong convergent and discriminant validity with the MI Treatment Integrity scales (MITI), the Therapist Empathy Scale (TES), and the Group Climate Questionnaire (GCQ). The AMIGOS shows promise as a reliable and valid measure of MI group leadership and group processes, and could be useful measuring other group therapies as well.

Convergence of online daily diaries and timeline followback among women at risk for alcohol exposed pregnancy.

Researchers and clinicians interested in assessing drinking and unprotected sex in evaluating risk for alcohol-exposed pregnancy (AEP) have limited options. The current investigation examined the degree to which data collected from online prospectively collected daily diaries (Diaries) converged with data from interviewer-administered retrospective timeline follow back (TLFB), the standard in AEP intervention studies. 71 women (Mage=27.7, SD=6.2) at risk for AEP were recruited via online advertising and were randomly assigned to an online patient education condition or a tailored, online internet intervention to reduce AEP risk. All participants were administered both Diaries and TLFB at baseline and 6months after intervention. Key outcomes were variables of drinking rates and unprotected sex that combined to indicate risk for AEP. Zero-order and intra-class correlations (ICC) between Diaries and TLFB were strong for each outcome. Examination of ICC confidence intervals indicated that condition assignment did not have a significant impact on the degree of convergence between Diaries and TLFB. With the exception of proportion of days drinking and proportion of days with unprotected sex at baseline, none of the paired t-tests reached significance. Examination of descriptive statistics revealed that 63% of participants reported problem alcohol use and unprotected sex in both the 10-day Diaries and 90-day TLFB at baseline, with 70% agreement at post 6-month follow up. Findings indicate overall strong agreement between TLFB and Diaries in detecting alcohol use and unprotected sex in women at risk for AEP, and each method has benefits and challenges that should be weighed carefully by researchers and treatment providers.

Predicting and Reducing Driving Mishaps Among Drivers With Type 1 Diabetes.

OBJECTIVE: Two aims of this study were to develop and validate A) a metric to identify drivers with type 1 diabetes at high risk of future driving mishaps and B) an online intervention to reduce mishaps among high-risk drivers. RESEARCH DESIGN AND METHODS: To achieve aim A, in study 1, 371 drivers with type 1 diabetes from three U.S. regions completed a series of established questionnaires about diabetes and driving. They recorded their driving mishaps over the next 12 months. Questionnaire items that uniquely discriminated drivers who did and did not have subsequent driving mishaps were assembled into the Risk Assessment of Diabetic Drivers (RADD) scale. In study 2, 1,737 drivers with type 1 diabetes from all 50 states completed the RADD online. Among these, 118 low-risk (LR) and 372 high-risk (HR) drivers qualified for and consented to participate in a 2-month treatment period followed by 12 monthly recordings of driving mishaps. To address aim B, HR participants were randomized to receive either routine care (RC) or the online intervention "DiabetesDriving.com" (DD.com). Half of the DD.com participants received a motivational interview (MI) at the beginning and end of the treatment period to boost participation and efficacy. All of the LR participants were assigned to RC. In both studies, the primary outcome variable was driving mishaps. RESULTS: Related to aim A, in study 1, the RADD demonstrated 61% sensitivity and 75% specificity. Participants in the upper third of the RADD distribution (HR), compared with those in the lower third (LR), reported 3.03 vs. 0.87 mishaps/driver/year, respectively (P < 0.001). In study 2, HR and LR participants receiving RC reported 4.3 and 1.6 mishaps/driver/year, respectively (P < 0.001). Related to aim B, in study 2, MIs did not enhance participation or efficacy, so the DD.com and DD.com + MI groups were combined. DD.com participants reported fewer hypoglycemia-related driving mishaps than HR participants receiving RC (P = 0.01), but more than LR participants receiving RC, reducing the difference between the HR and LR participants receiving RC by 63%. HR drivers differed from LR drivers at baseline across a variety of hypoglycemia and driving parameters. CONCLUSIONS: The RADD identified higher-risk drivers, and identification seemed relatively stable across time, samples, and procedures. This 11-item questionnaire could inform patients at higher risk, and their clinicians, that they should take preventive steps to reduce driving mishaps, which was accomplished in aim B using DD.com.