Effect of Computer-Tailored Print Feedback, Motivational Interviewing, and Motivational Enhancement Therapy on Engagement in Advance Care Planning: A Randomized Clinical Trial.

Importance: There is a tension between clinician-led approaches to engagement in advance care planning (ACP), which are effective but resource-intensive, and self-administered tools, which are more easily disseminated but rely on ability and willingness to complete. Objective: To examine the efficacy of computer-tailored print feedback (CTPF), motivational interviewing (MI), and motivational enhancement therapy (MET) on completion of a set of ACP activities, each as compared with usual care. Design, Setting, and Participants: This randomized clinical trial was conducted from October 2017 to December 2020 via telephone contact with primary care patients at a single VA facility; 483 veterans aged 55 years or older were randomly selected from a list of patients with a primary care visit in the prior 12 months, with oversampling of women and people from minoritized racial and ethnic groups. Statistical analysis was performed from January to June 2022. Interventions: Mailed CTPF generated in response to a brief telephone assessment of readiness to engage in and attitudes toward ACP; MI, an interview exploring ambivalence to change and developing a change plan; and MET, MI plus print feedback, delivered by telephone at baseline, 2, and 4 months. Main Outcome and Measures: Self-reported completion of 4 ACP activities: communicating about views on quality vs quantity of life, assignment of a health care agent, completion of a living will, and submitting documents for inclusion in the electronic health record at 6 months. Results: The study included 483 persons, mean (SD) age 68.3 (8.0) years, 18.2% women and 31.1% who were people from minoritized racial and ethnic groups. Adjusting for age, education, race, gender, and baseline stage of change for each ACP, predicted probabilities for completing the ACP activities were: usual care 5.7% (95% CI, 2.8%-11.1%) for usual care, 17.7% (95% CI, 11.8%-25.9%; P = .003) for MET, 15.8% (95% CI, 10.2%-23.6%; P = .01) for MI, P = .01, and 10.0% (95% CI, 5.9%-16.7%; P = .18) for CTPF. Conclusions and Relevance: This randomized clinical trial found that a series of 3 MI and MET counseling sessions significantly increased the proportion of middle-aged and older veterans completing a set of ACP activities, while print feedback did not. These findings suggest the importance of clinical interaction for ACP engagement. Trial Registration: ClinicalTrials.gov Identifier: NCT03103828.

Effect of the STAMP (Sharing and Talking About My Preferences) Intervention on Completing Multiple Advance Care Planning Activities in Ambulatory Care : A Cluster Randomized Controlled Trial.

BACKGROUND: Interventions with the potential for broad reach in ambulatory settings are necessary to achieve a life course approach to advance care planning. OBJECTIVE: To examine the effect of a computer-tailored, behavioral health model-based intervention on the engagement of adults in advance care planning recruited from ambulatory care settings. DESIGN: Cluster randomized controlled trial with participant-level analysis. (ClinicalTrials.gov: NCT03137459). SETTING: 10 pairs of primary and selected specialty care practices matched on patient sociodemographic information. PARTICIPANTS: English-speaking adults aged 55 years or older; 454 adults at practices randomly assigned to usual care and 455 at practices randomly assigned to intervention. INTERVENTION: Brief telephone or web-based assessment generating a mailed, individually tailored feedback report with a stage-matched brochure at baseline, 2 months, and 4 months. MEASUREMENTS: The primary outcome was completion of the following 4 advance care planning activities at 6 months: identifying and communicating with a trusted person about views on quality versus quantity of life, assignment of a health care agent, completion of a living will, and ensuring that the documents are in the medical record-assessed by a blinded interviewer. Secondary outcomes were completion of individual advance care planning activities. RESULTS: Participants were 64% women and 76% White. The mean age was 68.3 years (SD, 8.3). The predicted probability of completing all advance care planning activities in usual care sites was 8.2% (95% CI, 4.9% to 11.4%) versus 14.1% (CI, 11.0% to 17.2%) in intervention sites (adjusted risk difference, 5.2 percentage points [CI, 1.6 to 8.8 percentage points]). Prespecified subgroup analysis found no statistically significant interactions between the intervention and age, education, or race. LIMITATIONS: The study was done in a single region and excluded non-English speaking participants. No information was collected about nonparticipants. CONCLUSION: A brief, easily delivered, tailored print intervention increased participation in advance care planning in ambulatory care settings. PRIMARY FUNDING SOURCE: National Institute of Nursing Research and National Institute of Aging.

Understanding the Role of Knowledge in Advance Care Planning Engagement.

CONTEXT: Advance care planning remains underutilized. A better understanding of the role of education in promoting engagement is needed. OBJECTIVES: To examine advance care planning knowledge and its relationship to engagement in middle-aged and older adults. METHODS: This cross-sectional study utilized baseline data from 921 participants age ≥55 years enrolled in the STAMP randomized controlled trial, including a knowledge scale consisting of seven questions regarding the purpose and mechanisms of advance care planning and measures of participation. RESULTS: Only 11.9% of participants answered all 7 questions correctly, and 25.6% of participants answered ≤3 correctly (defined as "low knowledge"). Low knowledge was independently associated with male gender (odds ratio [OR] 2.1, 95% confidence interval [CI]: 1.5, 3.0), non-white race (OR 1.5, 95% CI: 1.1, 2.2), older age (OR 2.2, 95% CI: 1.4, 3.4), lower income (OR 1.5, 95% CI: 1.1, 2.1), and lower education level (OR 2.9, 95% CI: 2.0, 4.1). Higher knowledge was independently associated with communicating with a loved one about quality versus quantity of life (OR 1.7, 95% CI: 1.2, 2.4) and with living will completion (OR 1.6, 95% CI: 1.0, 2.5), but not with healthcare agent assignment. Factors including race and education remained associated with engagement after accounting for knowledge. CONCLUSION: Knowledge deficits regarding advance care planning are common and associated with the same sociodemographic factors linked to other healthcare disparities. While improving knowledge is an important component of intervention, it is unlikely sufficient in and of itself to increase engagement.

Implementing Coordinated Specialty Care in CMHC Youth and Young Adults with Severe Mental Illness: Preliminary Outcome Assessment.

This study assessed impact of Coordinated Specialty Care (CSC), expanded to include both first episode psychosis (FEP) and severe mental health disorders (e.g., depression, bipolar disorder, trauma) in youths attending Community Mental Health Centers (CMHCs). Eligible youth and young adults (ages 16-26 years, N = 201) were recruited from two CMHCs and assessed every 6 months. Paired sample t-tests were performed comparing pre- and post-treatment observations. Statistically significant decreases from pre to post were found in sad and anxious feelings and in days hospitalized for psychiatric emergency and increases were found in subjective health ratings and employment status. This preliminary assessment supports the effectiveness of expanded inclusion criteria for participation in the CSC model.

Identifying patient-level factors associated with interest in psychosocial services during cancer: A brief report.

OBJECTIVES: Uptake of psychosocial services during cancer treatment remains relatively low. To use these services efficiently, novel approaches - based on evidence-based theory - are needed to understand cancer patients' readiness to seek psychosocial services. Guided by the transtheoretical model (TTM), we investigated individuals' readiness to use psychosocial services by assessing decisional conflict (pros/cons) and self-efficacy, which are established as the most important constructs of predicting a specific behavior. METHODS: In these secondary analyses, we examined demographic and treatment-related factors in a national sample of adult cancer patients and survivors in the United States as predictors of decisional balance (pros/cons) and self-efficacy (i.e., two core TTM constructs) of engaging in psychosocial services. Participants were recruited through an online survey. In addition to examining demographic factors (age, sex, race, and marital status) as independent variables using t tests and correlations, treatment-related variables, such as having multiple cancers, type of cancer, type of treatment, and treatment setting were included. RESULTS: Four hundred and sixty-six participants completed the survey. The sample was primarily Caucasian (79%) and female (54.7%); average age was 47.9 (SD = 14.8). While no significant relationships emerged for self-efficacy, younger age and non-Caucasian race were significantly related to greater cons of seeking psychosocial care. Finally, those with multiple cancers versus reporting only one malignancy endorsed more cons of seeking psychosocial care. CONCLUSIONS: These data highlight the importance of measuring the cons of seeking psychosocial care during cancer treatment, with younger age, non-Caucasian, and those reporting experience with multiple cancers endorsing greater cons. This may impact eventual uptake of available services. Future research should identify individuals at risk for declining services based on perceived cons of seeking psychosocial care during cancer.

Development and Implementation of a Psychological Service for Patients With Cancer.

Cancer patients frequently experience considerable distress during diagnosis and treatment. The aims of this study were to describe the development and utilization of a psychological service for cancer patients at a community hospital-and to provide preliminary results on clinical outcomes in a "real-world" clinical setting. This program was developed collaboratively by individuals from a university-based clinical psychology doctoral program and a community hospital. The psychological service was comprised of a licensed, PhD-level clinical psychologist and seven clinical psychology doctoral students. Patients were typically referred by their oncologists or nurses. Distress, depression, and anxiety were evaluated for a small subsample of participants. From the time the program was initiated, 238 patients between ages 18 and 95 (M = 66.4) were evaluated over a 3-year period. Most patients (77.8%) were offered psychosocial care. Although 49.8% declined treatment, 23.6% attended one session and 26.6% attended two or more. Average number of individual sessions was 2.77 (SD=8.31, range=0-96) and 0.06 (SD=0.43, range=0-4) for groups sessions. Patients referred through the Survivorship Training and Rehabilitation (STAR) Program® (i.e., a program providing multidisciplinary services) were more likely to engage in psychosocial care than those who found out about behavioral health in other ways. Patients experienced declines in depression (Wilks' Λ=.580, F(2, 14)=5.08, p=.022), but not anxiety (Wilks' Λ=.613, F(2, 12)=3.79, p=.053) across sessions. An in-depth case description is provided. Distress tracking may be improved if nurses, oncologists, and behavioral health providers administer measures. Partnerships between clinical psychology doctoral programs and hospitals may be mutually beneficial - and may advance the dissemination and implementation of evidence-based psychosocial interventions. Hospitals offering cancer treatment may benefit from generating referrals for comprehensive cancer care. These efforts can serve as a model for other hospitals seeking to integrate behavioral health into routine cancer treatment.

Cross-validation of transtheoretical model smoking cessation measures in Chicago WIHS women smokers with and at risk for HIV.

People with and at risk for HIV have high rates of smoking, increasing their morbidity and mortality. Effective cessation interventions are needed for this group. Transtheoretical model (TTM)-tailored interventions have demonstrated efficacy, but measures need cross-validation in this population. TTM cessation measures were evaluated in women smokers with and at risk for HIV (N = 111) from Chicago Women's Interagency HIV Study (WIHS). Confirmatory factor analyses evaluated measurement models. MANOVAs examined relationships between constructs and stage subgroups. For decisional balance, the two-factor uncorrelated model was best (χ2(20) = 13.96; comparative fit index [CFI], 1.0; root mean square error of approximation [RMSEA] = .00), with good (pros α = .78) and fair (cons α = .55) four-item alphas. The one-factor temptations model (α = .90) showed reasonable fit (χ2(18) = 80.22; CFI = .89; RMSEA = .177). Processes of change subscales had fair to good two-item alphas (α = .49-.77) and fit a 10-factor fully correlated model (χ2(125) = 222.72; CFI = .88; RMSEA = .084). MANOVAs by stage of change replicated expected patterns for the pros, overall temptations, and two process subscales with medium-sized effects (η2 = .06-.18). Contrary to expectations, no differences by stage were found for cons or temptation negative affect subscales. The structures of these TTM measures replicated with good internal and external validity, except for the cons, which needs refinement. Negative affect temptations was structurally sound, but did not vary by stage group potentially reflecting this sample's moderate depression levels and/or their reliance on smoking to deal with negative affect. Results support the use of most TTM measures in research and tailored interventions to increase smoking cessation among women smokers with and at risk for HIV and highlight the importance of managing negative affect in cessation materials targeting this group.

Feasibility of Delivering a Tailored Intervention for Advance Care Planning in Primary Care Practice.

BACKGROUND/OBJECTIVES: To determine the feasibility of conducting a cluster randomized controlled trial providing individualized feedback reports to increase advance care planning (ACP) engagement in the primary care setting. DESIGN: Pilot cluster randomized controlled trial. SETTING: Two primary care practices selected for geographic colocation. PARTICIPANTS: Adults aged 55 years and older. INTERVENTION: Brief assessment of readiness to engage in (stage of change for) three ACP behaviors (healthcare agent assignment, communication with agent about quality vs quantity of life, and living will completion) generating an individualized feedback report, plus a stage-matched brochure. MEASURES: Patient recruitment and retention, intervention delivery, baseline characteristics, and stage of change movement. RESULTS: Recruitment rates differed by practice. Several baseline sociodemographic characteristics differed between the 38 intervention and 41 control participants, including employment status, education, and communication with healthcare agent. Feedback was successfully delivered to all intervention participants, and over 90% of participants completed a 2-month follow-up. More intervention participants demonstrated progression in readiness than did control participants, without testing for statistical significance. CONCLUSIONS: This pilot demonstrates opportunities and challenges of performing a clustered randomized controlled trial in primary care practices. Differences in the two practice populations highlight the challenges of matching sites. There was a signal for behavior change in the intervention group. J Am Geriatr Soc 67:1917-1921, 2019.

Longitudinal analysis of intervention effects on temptations and stages of change for dietary fat using parallel process latent growth modeling.

The Dietary Guidelines for Americans recommend a 20-35 percent daily intake of fat. Resisting the temptation to eat high-fat foods, in conjunction with stage of readiness to avoid these foods, has been shown to influence healthy behavior change. Data ( N = 6516) from three randomized controlled trials were pooled to examine the relationships among direct intervention effects on temptations and stage of change for limiting high-fat foods. Findings demonstrate separate simultaneous growth processes in which baseline level of temptations, but not the rate of change in temptations, was significantly related to the change in readiness to avoid high-fat foods.

Measures of psychosocial care utilization in a national sample of cancer patients.

OBJECTIVE: Cancer is one of the most physically and emotionally debilitating diseases. Despite evidence that psychosocial care can improve psychological and physiological functioning, as few as 4.4% of patients are willing to engage in psychosocial treatment. Few studies explored drivers of psychosocial care underutilization. Therefore, treatment engagement strategies are needed, by identifying patients' barriers to psychosocial treatment. This study evaluated readiness to utilize psychosocial care by developing transtheoretical model (TTM) measures of stage of change, decisional balance, and self-efficacy. METHOD: Online survey data was collected from a national sample of 475 adults (Mage = 47.89, SD = 14.77) with cancer diagnoses. A sequential process of measure development was used. Semistructured expert and research participant interviews were conducted for initial item development, followed by exploratory, confirmatory, and external validation analyses. RESULTS: Principal components analyses (PCA) indicated two, 4-item factors (pros α = .874; cons α = .716) for decisional balance. Confirmatory factor analyses (CFA) supported a 2-factor correlated model, χ²(19) = 68.56, CFI = .962, RMSEA = .078. For self-efficacy, PCA indicated two, 3-item components (physical α = .892; social/emotional α = .708). CFA supported this structure χ²(8) = 23.72, CFI = .989, RMSEA = .067. Physical component items included fatigue, pain, and discomfort. Multivariate analyses indicated significant cross-stage differences for pros, cons, and self-efficacy. CONCLUSIONS: Findings support the validity of the developed stage of change, 8-item decisional balance, and 6-item self-efficacy measures for psychosocial care. Clinicians could use these tools to address perceived cons of psychosocial care, including shame and self-efficacy (e.g., using psychosocial care despite pain). These scales may help treatment teams better address barriers to psychosocial care utilization. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Increasing engagement in advance care planning using a behaviour change model: study protocol for the STAMP randomised controlled trials.

INTRODUCTION: Advance care planning (ACP) is a key component of high-quality end-of-life care but is underused. Interventions based on models of behaviour change may fill an important gap in available programmes to increase ACP engagement. Such interventions are designed for broad outreach and flexibility in delivery. The purpose of the Sharing and Talking about My Preferences study is to examine the efficacy of three behaviour change approaches to increasing ACP engagement through two related randomised controlled trials being conducted in different settings (Veterans Affairs (VA) medical centre and community). METHODS AND ANALYSIS: Eligible participants are 55 years or older. Participants in the community are being recruited in person in primary care and specialty outpatient practices and senior living sites, and participants in the VA are recruited by telephone. In the community, randomisation is at the level of the practice or site, with all persons at a given practice/site receiving either computer-tailored feedback with a behaviour stage-matched brochure (computer-tailored intervention (CTI)) or usual care. At the VA, randomisation is at the level of the participant and is stratified by the number of ACP behaviours completed at baseline. Participants are randomised to one of four groups: CTI, motivational interviewing, motivational enhancement therapy or usual care. The primary outcome is completion of four key ACP behaviours: identification of a surrogate decision maker, communication about goals, completing advance directives and ensuring documents are in the medical record. Analysis will be conducted using mixed effects models, taking into account the clustered randomisation for the community study. ETHICS AND RANDOMISATION: The studies have been approved by the appropriate Institutional Review Boards and are being overseen by a Safety Monitoring Committee. The results of these studies will be disseminated to academic audiences and leadership in in the community and VA sites. TRIAL REGISTRATION NUMBERS: NCT03137459 and NCT03103828.

Community-based childhood obesity prevention intervention for parents improves health behaviors and food parenting practices among Hispanic, low-income parents.

BACKGROUND: Given the current prevalence of childhood obesity among Hispanic populations, and the importance of parental feeding behaviors, we aimed to assess the impact of the evidence-based Healthy Children, Healthy Families (HCHF) intervention on responsive food parenting practices (FPPs) in a low-income Hispanic population. METHODS: This community-based pilot study used a non-experimental pre/post within-subjects design. Parents (n = 94) of children aged 3-11 years old were recruited to participate in an 8-week, weekly group-based intervention. The intervention was delivered to nine groups of parents by trained paraprofessional educators over a two-year period. Children participated in a separate curriculum that covered topics similar to those covered in the parent intervention. Parents completed self-administered pre/post surveys, which included demographic questions, seven subscales from the Comprehensive Feeding Practices Questionnaire, and the 16-item HCHF Behavior Checklist. Descriptive statistics and paired samples t-tests were used to analyze data from parents that completed the intervention. RESULTS: Fifty-two, primarily Hispanic (93%) parents completed the intervention (39% attrition rate). For parents who completed the intervention, there was a significant increase in one of the feeding practice subscales: encouragement of balance and variety (p = 0.01). There were significant improvements in several parent and child diet and activity outcomes (p ≤ 0.01). CONCLUSIONS: Although attrition rates were high, parents completing the study reported enjoying and being satisfied with the intervention. For parents who completed the intervention, reported 'encouragement of balance and variety', in addition to several health behaviors significantly improved. Larger studies utilizing an experimental design, should further explore the impact of the HCHF curriculum on improving certain FPPs and health behaviors that contribute to obesity.

Integrated Primary Care Readiness and Behaviors Scale: Development and validation in behavioral health professionals.

INTRODUCTION: Although integrated primary care (IPC) is growing, several barriers remain. Better understanding of behavioral health professionals' (BHPs') readiness for and engagement in IPC behaviors could improve IPC research and training. This study developed measures of IPC behaviors and stage of change. METHOD: The sample included 319 licensed, practicing BHPs with a range of interests and experience with IPC. Sequential measurement development procedures, with split-half cross-validation were conducted. RESULTS: Exploratory principal components analyses (N = 152) and confirmatory factor analyses (N = 167) yielded a 12-item scale with 2 factors: consultation/practice management (CPM) and intervention/knowledge (IK). A higher-order Integrated Primary Care Behavior Scale (IPCBS) model showed good fit to the data, and excellent internal consistencies. The multivariate analysis of variance (MANOVA) on the IPCBS demonstrated significant large-sized differences across stage and behavior groups. DISCUSSION: The IPCBS demonstrated good psychometric properties and external validation, advancing research, education, and training for IPC practice. (PsycINFO Database Record

Sustainable Transportation and Health.

We are experiencing a shift in thinking about Transportation and Mobility, which makes this Special Issue on Sustainable Transportation and Health in the International Journal of Environmental Research and Public Health especially timely.[...].

Society of Behavioral Medicine (SBM) position statement: restore CDC funding for firearms and gun violence prevention research.

The Society for Behavioral Medicine (SBM) urges restoration of Centers for Disease Control and Prevention (CDC) funding for firearms and gun violence prevention research. Gun violence in the United States is an important and costly public health issue in need of research attention. Unfortunately, there have been no concerted CDC-funded research efforts in this area since 1996, due to the passage of the Dickey Amendment. To remedy the information-gathering restrictions caused by the Dickey Amendment bans, it is recommended that Congress remove 'policy riders' on federal appropriations bills that limit firearms research at the CDC; expand NVDRS firearms-related data collection efforts to include all fifty states; fund CDC research on the risk and protective factors of gun use and gun violence prevention; fund research on evidence-based primary, secondary, and tertiary prevention and treatment initiatives for communities that are seriously impacted by the effects of gun violence; and support the development of evidence-based policy and prevention recommendations for gun use and ownership.

Sustainable Transportation Attitudes and Health Behavior Change: Evaluation of a Brief Stage-Targeted Video Intervention.

Promoting physical activity and sustainable transportation is essential in the face of rising health care costs, obesity rates, and other public health threats resulting from lack of physical activity. Targeted communications can encourage distinct population segments to adopt active and sustainable transportation modes. Our work is designed to promote the health, social, and environmental benefits of sustainable/active transportation (ST) using the Transtheoretical Model of Change (TTM), which has been successfully applied to a range of health, and more recently, sustainability behaviors. Earlier, measurement development confirmed both the structure of ST pros and cons and efficacy measures as well as the relationship between these constructs and ST stages of change, replicating results found for many other behaviors. The present paper discusses a brief pre-post video pilot intervention study designed for precontemplators and contemplators (N = 604) that was well received, effective in moving respondents towards increased readiness for ST behavior change, and improving some ST attitudes, significantly reducing the cons of ST. This research program shows that a brief stage-targeted behavior change video can increase readiness and reduce the cons for healthy transportation choices.

Psychometric assessment of the processes of change scale for sun protection.

The fourteen-factor Processes of Change Scale for Sun Protection assesses behavioral and experiential strategies that underlie the process of sun protection acquisition and maintenance. Variations of this measure have been used effectively in several randomized sun protection trials, both for evaluation and as a basis for intervention. However, there are no published studies, to date, that evaluate the psychometric properties of the scale. The present study evaluated factorial invariance and scale reliability in a national sample (N = 1360) of adults involved in a Transtheoretical model tailored intervention for exercise and sun protection, at baseline. Invariance testing ranged from least to most restrictive: Configural Invariance (constraints only factor structure and zero loadings); Pattern Identity Invariance (equal factor loadings across target groups); and Strong Factorial Invariance (equal factor loadings and measurement errors). Multi-sample structural equation modeling tested the invariance of the measurement model across seven subgroups: age, education, ethnicity, gender, race, skin tone, and Stage of Change for Sun Protection. Strong factorial invariance was found across all subgroups. Internal consistency coefficient Alpha and factor rho reliability, respectively, were .83 and .80 for behavioral processes, .91 and .89 for experiential processes, and .93 and .91 for the global scale. These results provide strong empirical evidence that the scale is consistent, has internal validity and can be used in research interventions with population-based adult samples.