Impact of barriers and motivators on intention and confidence to undergo hereditary cancer genetic testing.

Genetic testing for hereditary cancer syndromes can provide lifesaving information allowing for individualized cancer screening, prevention, and treatment. However, the determinants, both barriers and motivators, of genetic testing intention are not well described. A survey of barriers and motivators to genetic testing was emailed to adult patients eligible for genetic testing based on cancer diagnosis who previously have not had genetic testing (n = 201). Associations between barriers/motivators with testing intention and confidence were examined first by correlation followed by multivariable linear regression model holding constant potential covariates. Seven barrier items from two domains (logistics and genetic testing knowledge) were found to significantly negatively correlate with genetic testing intention. Unexpectedly, three barrier items had significant positive correlation with genetic testing intention; these were related to family worry (passing a condition on to future generations) and testing knowledge (needing more information on the genetic testing process and what it has to offer). Ten barrier items had significant negative correlation with confidence to get a genetic test and encompassed four domains: stigma, insurance/genetic discrimination, knowledge, and cost. All motivator items were associated with intention to get a genetic test, while none were associated with confidence. Multivariable analysis yielded six total barriers (five from the knowledge domain, one from cost domain) and two motivators (relieved to know and treatment impact) that were significantly associated with genetic testing intention or confidence when controlling for demographic characteristics. These findings indicate the need for tailored interventions to amplify motivating factors and counter-message barriers to enhance patient motivation and confidence to undergo testing.

Cultural Sensitivity and Cultural Tailoring: Lessons Learned and Refinements After Two Decades of Incorporating Culture in Health Communication Research.

In this article, we examine progress and challenges in designing, implementing, and evaluating culturally sensitive behavioral interventions by tailoring health communication to groups or individuals. After defining common tailoring constructs (i.e., culture, race, and ethnicity), cultural sensitivity, and cultural tailoring, we examine when it is useful to culturally tailor and address cultural sensitivity in health communication by group tailoring or individual tailoring and when tailoring health communication may not be necessary or appropriate for achieving behavior change. After reviewing selected approaches to cultural tailoring, we critique the quality of research in this domain with a focus on the internal validity of empirical findings. Then we explore the ways in which cultural sensitivity, group targeting, and individual tailoring have incorporated culture in health promotion and health communication. We conclude by articulating yet unanswered questions and suggesting future directions to move the field forward. Expected final online publication date for the Annual Review of Public Health, Volume 45 is April 2024. Please see http://www.annualreviews.org/page/journal/pubdates for revised estimates.

The Support, Educate, Empower personalized glaucoma coaching trial design.

BACKGROUND: Glaucoma is a chronic disease that affects 3 million Americans. Glaucoma is most often asymptomatic until very late in its course when treatment is more difficult and extensive peripheral vision loss has already occurred. Taking daily medications can mitigate this vision loss, but at least half of people with glaucoma do not take their prescribed medications regularly. The purpose of this study is to improve glaucoma medication adherence among those with medically treated glaucoma and poor self-reported adherence using the Support, Educate, Empower personalized coaching program. METHODS/DESIGN: This study is a two-site randomized controlled trial enrolling 230 participants with poor self-reported glaucoma medication adherence. The trial has two arms, an intervention arm and a control arm. Participants in the intervention arm receive personalized glaucoma education and motivational interviewing-based coaching over 6 months from a trained non-physician interventionist for three in-person sessions with between visit phone calls for check-ins where current adherence level is reported to participants. Participants also can elect to have visual, audio, text or automated phone call medication dose reminders. Participants in the control arm continue usual care with their physician and receive non-personalized glaucoma educational materials via mail in parallel to the three in-person coaching sessions to control for glaucoma knowledge content. All participants receive a medication adherence monitor. The primary outcome is the proportion of prescribed doses taken on schedule during the 6-month period. The secondary outcome is glaucoma related distress. The exploratory outcome is intraocular pressure. DISCUSSION: The personalized education and motivational-interviewing-based intervention that we are testing is comprehensive in that it addresses the wide range of barriers to adherence that people with glaucoma encounter. Leveraging a custom-built web-based application to generate the personalized content and the motivational-interviewing-based prompts to guide the coaching sessions will make this program both replicable and scalable and can be integrated into clinical care utilizing trained non-physician providers. Although this type of self-management support is not currently reimbursed for glaucoma as it is for diabetes, this trial could help shape future policy change should the intervention be found effective.

Implementing text-messaging to support and enhance delivery of health behavior change interventions in low- to middle-income countries: case study of the Lifestyle Africa intervention.

The prevalence of non-communicable diseases, such as diabetes and cardiovascular disease, is rising in low- and middle-income countries (LMICs). Health behavior change (HBC) interventions such as the widely used Diabetes Prevention Program (DPP) are effective at reducing chronic disease risk, but have not been adapted for LMICs. Leveraging mobile health (mHealth) technology such as text messaging (SMS) to enhance reach and participant engagement with these interventions has great promise, yet we lack evidence-informed approaches to guide the integration of SMS specifically to support HBC interventions in LMIC contexts. To address this gap, we integrated guidance from the mHealth literature with expertise and first-hand experience to establish specific development steps for building and implementing SMS systems to support HBC programming in LMICs. Specifically, we provide real-world examples of each development step by describing our experience in designing and delivering an SMS system to support a culturally-adapted DPP designed for delivery in South Africa. We outline eight key SMS development steps, including: 1) determining if SMS is appropriate; 2) developing system architecture and programming; 3) developing theory-based messages; 4) developing SMS technology; 5) addressing international SMS delivery; 6) testing; 7) system training and technical support; and 8) cost considerations. We discuss lessons learned and extractable principles that may be of use to other mHealth and HBC researchers working in similar LMIC contexts.Trial registration Clinicaltrials.gov, NCT03342274 . Registered 10 November 2017.

Evaluation of an adapted version of the Diabetes Prevention Program for low- and middle-income countries: A cluster randomized trial to evaluate "Lifestyle Africa" in South Africa.

BACKGROUND: Low- and middle-income countries (LMICs) are experiencing major increases in diabetes and cardiovascular conditions linked to overweight and obesity. Lifestyle interventions such as the United States National Diabetes Prevention Program (DPP) developed in high-income countries require adaptation and cultural tailoring for LMICs. The objective of this study was to evaluate the efficacy of "Lifestyle Africa," an adapted version of the DPP tailored for an underresourced community in South Africa compared to usual care. METHODS AND FINDINGS: Participants were residents of a predominantly Xhosa-speaking urban township of Cape Town, South Africa characterized by high rates of poverty. Participants with body mass index (BMI) ≥ 25 kg/m2 who were members of existing social support groups or "clubs" receiving health services from local nongovernmental organizations (NGOs) were enrolled in a cluster randomized controlled trial that compared Lifestyle Africa (the intervention condition) to usual care (the control condition). The Lifestyle Africa intervention consisted of 17 video-based group sessions delivered by trained community health workers (CHWs). Clusters were randomized using a numbered list of the CHWs and their assigned clubs based on a computer-based random allocation scheme. CHWs, participants, and research team members could not be blinded to condition. Percentage weight loss (primary outcome), hemoglobin A1c (HbA1c), blood pressure, triglycerides, and low-density lipoprotein (LDL) cholesterol were assessed 7 to 9 months after enrollment. An individual-level intention-to-treat analysis was conducted adjusting for clustering within clubs and baseline values. Trial registration is at ClinicalTrials.gov (NCT03342274). Between February 2018 and May 2019, 782 individuals were screened, and 494 were enrolled. Participants were predominantly retired (57% were receiving a pension) and female (89%) with a mean age of 68 years. Participants from 28 clusters were allocated to Lifestyle Africa (15, n = 240) or usual care (13, n = 254). Fidelity assessments indicated that the intervention was generally delivered as intended. The modal number of sessions held across all clubs was 17, and the mean attendance of participants across all sessions was 61%. Outcome assessment was completed by 215 (90%) intervention and 223 (88%) control participants. Intent-to-treat analyses utilizing multilevel modeling included all randomized participants. Mean weight change (primary outcome) was -0.61% (95% confidence interval (CI) = -1.22, -0.01) in Lifestyle Africa and -0.44% (95% CI = -1.06, 0.18) in control with no significant difference (group difference = -0.17%; 95% CI = -1.04, 0.71; p = 0.71). However, HbA1c was significantly lower at follow-up in Lifestyle Africa compared to the usual care group (mean difference = -0.24, 95% CI = -0.39, -0.09, p = 0.001). None of the other secondary outcomes differed at follow-up: systolic blood pressure (group difference = -1.36; 95% CI = -6.92, 4.21; p = 0.63), diastolic blood pressure (group difference = -0.39; 95% CI = -3.25, 2.30; p = 0.78), LDL (group difference = -0.07; 95% CI = -0.19, 0.05; p = 0.26), triglycerides (group difference = -0.02; 95% CI = -0.20, 0.16; p = 0.80). There were no unanticipated problems and serious adverse events were rare, unrelated to the intervention, and similar across groups (11 in Lifestyle Africa versus 13 in usual care). Limitations of the study include the lack of a rigorous dietary intake measure and the high representation of older women. CONCLUSIONS: In this study, we found that Lifestyle Africa was feasible for CHWs to deliver and, although it had no effect on the primary outcome of weight loss or secondary outcomes of blood pressure or triglycerides, it had an apparent small significant effect on HbA1c. The study demonstrates the potential feasibility of CHWs to deliver a program without expert involvement by utilizing video-based sessions. The intervention may hold promise for addressing cardiovascular disease (CVD) and diabetes at scale in LMICs. TRIAL REGISTRATION: ClinicalTrials.gov NCT03342274.

The Results of the Families Improving Together (FIT) for Weight Loss Randomized Trial in Overweight African American Adolescents.

BACKGROUND: Few intervention studies have integrated cultural tailoring, parenting, behavioral, and motivational strategies to address African American adolescent weight loss. PURPOSE: The Families Improving Together (FIT) for Weight Loss trial was a randomized group cohort study testing the efficacy of a cultural tailoring, positive parenting, and motivational intervention for weight loss in overweight African American adolescents (N = 241 adolescent/caregiver dyads). METHODS: The trial tested an 8-week face-to-face group motivational plus family weight loss program (M + FWL) compared with a comprehensive health education control program. Participants were then rerandomized to an 8-week tailored or control online program to test the added effects of the online intervention on reducing body mass index and improving physical activity (moderate-to-vigorous physical activity [MVPA], light physical activity [LPA]), and diet. RESULTS: There were no significant intervention effects for body mass index or diet. There was a significant effect of the group M + FWL intervention on parent LPA at 16 weeks (B = 33.017, SE = 13.115, p = .012). Parents in the group M + FWL intervention showed an increase in LPA, whereas parents in the comprehensive health education group showed a decrease in LPA. Secondary analyses using complier average causal effects showed a significant intervention effect at 16 weeks for parents on MVPA and a similar trend for adolescents. CONCLUSIONS: While the intervention showed some impact on physical activity, additional strategies are needed to impact weight loss among overweight African American adolescents.

Comparative predictors for cervical cancer screening in Southeast Michigan for Middle Eastern-North African (MENA), White and African American/black women.

The cervical cancer screening behaviors of Arab American women are not adequately understood, in part because Middle Eastern North African (MENA) descent is not a US Census category. Others have shown decreased cervical cancer screening in this race of women. Our primary aim is to evaluate the predictors of cervical cancer screening among MENA, White and Black women of southeast Michigan. A community-wide health survey reached MENA, White and Black populations asking self-report questions about health behaviors, attitudes, and medical history. Cervical cancer screening was considered up-to-date if it was reported to have occurred within the past three years. Survey responses were limited to women 30-65 years old and were analyzed with inferential and logistic regression models to determine risk factors for cervical cancer screening. Overall, 78% reported cervical cancer screening within the past three years. MENA women screened less often if time in the US was less than ten years (aOR 0.24 (0.05, 0.76)) compared to more than ten years and if single (aOR 0.27 (0.07, 0.97)) compared to married. Religion was not associated with screening in any study population. Those of all races without insurance screened significantly less often than those with insurance. The barriers to cervical cancer screening among MENA women are not associated with religion but instead with lack of insurance and length of time residing in the US.

Understanding factors associated with firearm possession: Examining differences between male and female adolescents and emerging adults seeking emergency department care.

Firearm possession increases the likelihood of hospital visits among adolescents and emerging adults for both males and females. To better inform prevention practices, we examine data among adolescents and emerging adults (A/EAs; ages 16 to 29) presenting to an urban emergency department for any reason to understand the differences in firearm possession between males and females (N = 1312; 29.6% male; 50.5% Black). Regression identified firearm possession correlates, such as male sex (AOR = 2.26), firearm attitudes (AOR = 1.23), peer firearm possession (AOR = 9.84), and community violence exposure (AOR = 1.02). When stratified by sex (e.g., male vs female), regression results yielded differences in correlates for firearm possession: in males, peer firearm possession (AOR = 8.96) were significant, and in females, firearm attitudes (AOR = 1.33) and peer firearm possession (AOR = 11.24) were significant. An interaction between sex and firearm attitudes demonstrated that firearm attitudes were differentially associated with firearm possession between female and male A/EAs (AOR = 1.28). Overall, we found that females are more likely to endorse retaliatory firearm attitudes, and both males and females are highly influenced by their perception of peer firearm possession. These results help inform prevention strategies across multiple settings, especially for hospital-based violence interventions, and suggest that tailored approaches addressing differences between male and female A/EAs are appropriate when addressing firearm violence and injury risk among A/EAs.

Individual differences in the effects of the ACTION-PAC intervention: an application of personalized medicine in the prevention and treatment of obesity.

There is an increased interest in the use of personalized medicine approaches in the prevention or treatment of obesity, however, few studies have used these approaches to identify individual differences in treatment effects. The current study demonstrates the use of the predicted individual treatment effects framework to test for individual differences in the effects of the ACTION-PAC intervention, which targeted the treatment and prevention of obesity in a high school setting. We show how methods for personalized medicine can be used to test for significant individual differences in responses to an intervention and we discuss the potential and limitations of these methods. In our example, 25% of students in the preventive intervention, were predicted to have their BMI z-score reduced by 0.39 or greater, while at other end of the spectrum, 25% were predicted to have their BMI z-score increased by 0.09 or more. In this paper, we demonstrate and discuss the process of using methods for personalized medicine with interventions targeting adiposity and discuss the lessons learned from this application. Ultimately, these methods have the potential to be useful for clinicians and clients in choosing between treatment options, however they are limited in their ability to help researchers understand the mechanisms underlying these predictions.

Motivational interviewing for genetic counseling: A unified framework for persuasive and equipoise conversations.

Genetic counselors (GCs) have traditionally been trained to adopt a position of equipoise or clinical neutrality. They provide information, answer questions, address barriers, and engage in shared decision-making, but generally, they do not prescribe a genetic test. Historically, GCs have generally been trained not to persuade the ambivalent or resistant patient. More recently, however, there has been discussion regarding when a greater degree of persuasion or directionality may be appropriate within genetic counseling (GC) and what role MI may play in this process. The role for "persuasive GC" is based on the premise that some genetic tests provide actionable information that would clearly benefit patients and families by impacting treatment or surveillance. For other tests, the benefits are less clear as they do not directly impact patient care or the benefits may be more subjective in nature, driven by patient values or psychological needs. For the former, we propose that GCs may adopt a more persuasive clinical approach while for the latter, a more traditional equipoise stance may be more appropriate. We suggest that motivational interviewing (MI) could serve as a unifying counseling model that allows GCs to handle both persuasive and equipoise encounters. For clearly beneficial tests, while directional, the MI encounter can still be non-directive, autonomy-supportive, and patient-centered. MI can also be adapted for equipoise situations, for example, placing less emphasis on eliciting and strengthening change talk as that is more a behavior change strategy than a shared decision-making strategy. The core principles and strategies of MI, such as autonomy support, evocation, open questions, reflective listening, and affirmation would apply to both persuasive and equipoise encounters. Key issues that merit discussion include how best to train GCs both during their initial and post-graduate education.

Lessons Learned From Beta-Testing a Facebook Group Prototype to Promote Treatment Use in the "Connecting Alaska Native People to Quit Smoking" (CAN Quit) Study.

Social media provides an effective tool to reach, engage, and connect smokers in cessation efforts. Our team developed a Facebook group, CAN Quit (Connecting Alaska Native People to Quit smoking), to promote use of evidence-based smoking cessation resources for Alaska Native people living in Alaska, which are underused despite their effectiveness. Often separated by geography and climate, Alaska Native people prefer group-based approaches for tobacco cessation that support their culture and values. Such preferences make Alaska Native people candidates for social media-based interventions that promote connection. This viewpoint discusses the steps involved and lessons learned in building and beta-testing our Facebook group prototype, which will then be evaluated in a pilot randomized controlled trial. We describe the process of training moderators to facilitate group engagement and foster community, and we describe how we developed and tested our intervention prototype and Facebook group. All parts of the prototype were designed to facilitate use of evidence-based cessation treatments. We include recommendations for best practices with the hope that lessons learned from the CAN Quit prototype could provide a model for others to create similar platforms that benefit Alaska Native and American Indian people in the context of smoking cessation.

Translating Violence Prevention Programs from Research to Practice: SafERteens Implementation in an Urban Emergency Department.

BACKGROUND: Youth violence is a leading cause of adolescent mortality, underscoring the need to integrate evidence-based violence prevention programs into routine emergency department (ED) care. OBJECTIVES: To examine the translation of the SafERteens program into clinical care. METHODS: Hospital staff provided input on implementation facilitators/barriers to inform toolkit development. Implementation was piloted in a four-arm effectiveness-implementation trial, with youth (ages 14-18 years) screening positive for past 3-month aggression randomized to either SafERteens (delivered remotely or in-person) or enhanced usual care (EUC; remote or in-person), with follow-up at post-test and 3 months. During maintenance, ED staff continued in-person SafERteens delivery and external facilitation was provided. Outcomes were measured using the RE-AIM implementation framework. RESULTS: SafERteens completion rates were 77.6% (52/67) for remote and 49.1% (27/55) for in-person delivery. In addition to high acceptability ratings (e.g., helpfulness), post-test data demonstrated increased self-efficacy to avoid fighting among patients receiving remote (incidence rate ratio [IRR] 1.22, 95% confidence interval [CI] 1.09-1.36) and in-person (IRR 1.23, 95% CI 1.12-1.36) SafERteens, as well as decreased pro-violence attitudes among patients receiving remote (IRR 0.83, 95% CI 0.75-0.91) and in-person (IRR 0.87, 95% CI 0.77-0.99) SafERteens when compared with their respective EUC groups. At 3 months, youth receiving remote SafERteens reported less non-partner aggression (IRR 0.52, 95% CI 0.31-0.87, Cohen's d -0.39) and violence consequences (IRR 0.47, 95% CI 0.22-1.00, Cohen's d -0.49) compared with remote EUC; no differences were noted for in-person SafERteens delivery. Barriers to implementation maintenance included limited staff availability and a lack of reimbursement codes. CONCLUSIONS: Implementing behavioral interventions such as SafERteens into routine ED care is feasible using remote delivery. Policymakers should consider reimbursement for violence prevention services to sustain long-term implementation.

Relationship Between Coronavirus-Related eHealth Literacy and COVID-19 Knowledge, Attitudes, and Practices among US Adults: Web-Based Survey Study.

BACKGROUND: During a global pandemic, it is critical that the public is able to rapidly acquire new and accurate health information. The internet is a major source of health information. eHealth literacy is the ability of individuals to find, assess, and use health information available on the internet. OBJECTIVE: The goals of this study were to assess coronavirus-related eHealth literacy and examine the relationship between eHealth literacy and COVID-19-related knowledge, attitudes, and practices (KAPs). METHODS: We conducted a web-based survey of a representative sample of 1074 US adults. We adapted the 8-item eHealth Literacy Scale to develop the Coronavirus-Related eHealth Literacy Scale (CoV-eHEALS) to measure COVID-19-related knowledge, conspiracy beliefs, and adherence to protective behaviors (eg, wearing facial masks and social distancing). Our analyses identified sociodemographic associations with the participants' CoV-eHEALS scores and an association between the CoV-eHEALS measure and COVID-19 KAPs. RESULTS: The internal consistency of the adapted CoV-eHEALS measure was high (Cronbach α=.92). The mean score for the CoV-eHEALS was 29.0 (SD 6.1). A total of 29% (306/1074) of the survey participants were classified as having low coronavirus-related eHealth literacy (CoV-eHEALS score <26). Independent associations were found between CoV-eHEALS scores and ethnicity (standardized ß=-.083, P=.016 for Black participants) and education level (standardized ß=-.151, P=.001 for participants with high-school education or lower). Controlling for demographic characteristics, CoV-eHEALS scores demonstrated positive independent associations with knowledge (standardized ß=.168, P<.001) and adherence to protective behaviors (standardized ß=.241, P<.001) and a negative association with conspiracy beliefs (standardized ß=-.082, P=.009). CONCLUSIONS: This study provides an estimate of coronavirus-related eHealth literacy among US adults. Our findings suggest that a substantial proportion of US adults have low coronavirus-related eHealth literacy and are thus at a greater risk of lower and less-protective COVID-19 KAPs. These findings highlight the need to assess and address eHealth literacy as part of COVID-19 control efforts. Potential strategies include improving the quality of health information about COVID-19 available on the internet, assisting or simplifying web-based search for information about COVID-19, and training to improve general or coronavirus-specific search skills.

Novel Predictors of COVID-19 Protective Behaviors Among US Adults: Cross-sectional Survey.

BACKGROUND: A central component of the public health strategy to control the COVID-19 pandemic involves encouraging mask wearing and social distancing to protect individuals from acquiring and transmitting the virus. OBJECTIVE: This study aims to understand the psychological factors that drive adoption or rejection of these protective behaviors, which can inform public health interventions to control the pandemic. METHODS: We conducted an online survey of a representative sample of 1074 US adults and assessed three novel potential predictors of COVID-19 behaviors: trait reactance, COVID-19 conspiracy beliefs, and COVID-19 apocalypse beliefs. Key outcomes (dependent variables) included an index of COVID-19 protective behaviors, the number of trips taken from the home, and COVID-19 knowledge. RESULTS: In bivariate analyses, all three predictors were significantly correlated in the hypothesized direction with the three COVID-19 outcomes. Specifically, each predictor was negatively (P<.01) correlated with the COVID-19 protective behaviors index and COVID-19 knowledge score, and positively correlated with trips taken from home per week (more of which was considered higher risk). COVID-19 protective behaviors and COVID-19 knowledge were significantly lower in the top median compared to the bottom median for all three predictors. In general, these findings remained significant after adjusting for all novel predictors plus age, gender, income, education, race, political party, and religiosity. Self-identified Republicans (vs other political affiliations) reported the highest values for each of the novel predictors. CONCLUSIONS: This study can inform the development of health communication interventions to encourage the adoption of COVID-19 protective behaviors. Interestingly, we found that higher scores of all three novel predictors were associated with lower COVID-19 knowledge, suggesting that lack of an accurate understanding of the virus may be driving some of these attitudes; although, it is also possible that these attributes may interfere with one's willingness or ability to seek and absorb accurate health information. These individuals may be particularly immune to accepting new information and yielding their beliefs. Health communication professionals may apply lessons learned from countering similar beliefs around climate change and vaccine hesitancy. Messages designed for individuals prone to reactance may be more effective if they minimize controlling language and emphasize the individual's independence in adopting these behavioral recommendations. Messaging for those who possess conspiracy beliefs should similarly not assume that providing evidence contrary to these beliefs will alone alter behavior. Other communication techniques such as rolling with resistance, a strategy used in motivational interviewing, may be helpful. Messaging for those with apocalyptic beliefs may require using religious leaders as the message source and using scripture that would support the adoption of COVID-19 protection behaviors.

Screen time use impacts low-income preschool children's sleep quality, tiredness, and ability to fall asleep.

BACKGROUND: Sleep is increasingly recognized as a vital part of health. Screen time has been linked to sleep quality in children. The purpose of this study was to analyze associations between screen time and sleep characteristics among low-income preschoolers. METHODS: A total of 1,700 preschool-aged children participated in this study at 50 federally and state-funded preschool centers in Michigan. Baseline measurement for an ongoing longitudinal intervention trial was obtained for cross-sectional use. At baseline, parents reported the number of hours their child spent engaging in screen time on a typical week day and weekend. An aggregate measure of total screen time was created. Parents reported on the quality of their child's sleep, how often they were tired during the day, and whether they had difficulty falling asleep. A mixed model linear regression was created to analyze data. RESULTS: Controlling for child's age, race, and parental income, children who engaged in more screen time were significantly more likely to have more trouble falling or staying asleep, be tired during the day, and had worse quality of sleep (P values = .004, .006 and .001, respectively). Spearman correlations of screen time, sleep variables and demographics show parents of Black children reported significantly higher weekly screen time than parents of non-Black children (r = 0.23, P < .001) and that tiredness was associated with Black race (r = 0.15, P < .001), Hispanic/Latino ethnicity (r = -0.14, P < .001), and parental education (r = 0.06, P = .016). CONCLUSION: This report confirms prior associations between screen time and sleep reported in other pediatric populations. Further research is needed to confirm these results in other populations using more rigorous measures of screen time, sleep, and physical activity, as well as longitudinal assessments. Despite these limitations, findings suggest that interventions to help parents limit children's screen time and impact their sleep health merit investigation.

Process Evaluation of a Faith-Based Multicomponent Behavioral Intervention to Reduce Stroke Risk in Mexican Americans in a Catholic Church Setting: The SHARE (Stroke Health and Risk Education) Project.

Church-based stroke prevention programs for Hispanics are underutilized. The Stroke Health and Risk Education (SHARE) project, a multicomponent cluster-randomized trial, addressed key stroke risk factors among predominantly Mexican Americans in a Catholic Church setting. Process evaluation components (implementation, mechanisms of impact, and context) are described. Partner support promoted positive health behavior change. Motivational interviewing calls were perceived as helpful, however, barriers with telephone delivery were encountered. Intervention exposure was associated with theory constructs for targeted behaviors. We conclude that health behavior interventions to prevent stroke can be successfully implemented for Mexican Americans within a Catholic Church setting, with parish priest support.

Rates and correlates of risky firearm behaviors among adolescents and young adults treated in an urban emergency department.

Firearm violence is a leading cause of death for urban adolescents and young adults (A/YAs). Little is known about patterns of risky firearm behaviors (RFBs) that may increase firearm-related fatality and non-fatal injury risk. To inform prevention efforts, we examined the rates and correlates of RFBs, including firearm carriage in risky situations (e.g., while drunk/high), discharge in risky situations (e.g., fleeing police), and firearm aggression (e.g., firearm threats/use against a partner/non-partner), among a sample of A/YAs (age-16-29) seeking medical or injury related care (7/2017-6/2018) at a Level-1 urban Emergency Department (ED). In total, 1312 A/YAs completed the survey (mean-age 23.2; 29.6%-male; 50.5%-Black; 56.3%-public assistance), with 102 (7.8%) engaging in RFBs. Among those engaging in RFBs, 42% reported firearm ownership, 68.6% firearm carriage in high-risk situations, 39.2% firearm discharge in risky situations, and 41.2% reported partner/non-partner firearm aggression. Regression identified RFBs correlates, including older age (AOR = 1.09), male sex (AOR = 1.63), Black race/ethnicity (AOR = 2.01), substance misuse (AOR = 2.75), attitudes favoring firearm use/retaliation (AOR = 1.38), peer firearm ownership/carriage (AOR = 3.26), higher levels of community violence exposure (AOR = 1.05), and active parole/probation (AOR 2.38). Higher coping skills were protective for RFBs (AOR = 0.83). Overall, we found that A/YAs seeking urban ED treatment reported elevated RFB rates, emphasizing the need for novel prevention initiatives, especially those incorporating tailored content addressing substance use, retaliatory violence, and peer delinquency/norms, while enhancing self-efficacy for avoiding RFBs and providing access to external resources within a resiliency-based framework. Such prevention approaches may be a critical step towards addressing the public health problem of firearm violence. Primary Funding Sources: NIH/NIDA K23DA039341; NIH/NCATS UL1TR000433.

A Glaucoma-Specific Brief Motivational Interviewing Training Program for Ophthalmology Para-professionals: Assessment of Feasibility and Initial Patient Impact.

Our objective was to test the feasibility of, fidelity to, and initial impact of a brief, glaucoma-specific motivational interviewing (MI) training program for ophthalmic para-professionals. This prospective, mixed-methods study had two components, one for staff and one for patients. Staff fidelity to MI principles was graded through audio-recorded encounters after initial and final training sessions. After training, patients graded staff for adherence to autonomy supportive care. Semi-structured interviews with para-professionals elicited feedback about the training and about their ability to implement MI in the clinic. The impact on patient satisfaction with staff communication, eye drop instillation self-efficacy, and overall health activation was assessed using a survey pre- and post-training. Para-professionals met two of three program goals for MI skills and improved in their overall scores for MI fidelity. Para-professionals noted lack of time in the clinic as a significant barrier to implementing counseling. Patient satisfaction with staff communication increased after the training (p = 0.04) among patients who rated their staff above the mean for providing autonomy supportive care. The intervention did not improve patients' eye drop instillation self-efficacy or overall health activation. Training para-professional staff in brief, glaucoma-specific MI techniques is feasible and may improve patient satisfaction, though dedicated time in clinic is needed to implement MI counseling into glaucoma practice.

Physician attitudes about cost consciousness for breast cancer treatment: differences by cancer sub-specialty.

PURPOSE: High costs of cancer care place considerable burden on patients and society. Despite increasing recognition that providers should play a role in reducing care costs, how physicians across cancer specialties differ in their cost-consciousness has not been reported. We examined cost-consciousness regarding breast cancer care among medical oncologists, surgeons, and radiation oncologists. METHODS: We identified 514 cancer surgeons, 504 medical oncologists, and 251 radiation oncologists by patient report through the iCanCare study. iCanCare identified newly diagnosed women with breast cancer through the Surveillance, Epidemiology, and End Results (SEER) registries of Georgia and Los Angeles. We queried providers on three dimensions of cost-consciousness: (1) perceived importance of cost saving for society, patients, practice, and payers; (2) awareness of patient out-of-pocket expenses; and (3) discussion of financial burden. RESULTS: We received responses from 376 surgeons (73%), 304 medical oncologists (60%), and 169 radiation oncologists (67%). Overall levels of cost-consciousness were moderate, with scores ranging from 2.5 to 3.0 out of 5. After adjusting for covariates, surgeons had the lowest scores on all three cost-consciousness measures; medical oncologists had the highest scores. Pairwise contrasts showed surgeons had significantly lower scores than medical oncologists for all three measures and significantly lower scores than radiation oncologists for two of the three cost-consciousness variables: importance of cost saving and discussion of financial burden. CONCLUSIONS: How cost-consciousness impacts medical decision-making across specialty and how policy, structural, and behavioral interventions might sensitize providers regarding cost-related matters merit further examination.

Web-Based Program Exposure and Retention in the Families Improving Together for Weight Loss Trial.

BACKGROUND: Interventions that incorporate behavioral skills training and parental involvement have been effective for promoting weight loss among middle and upper class youth; however, few studies have produced similar weight loss effects in underserved ethnic minority youth. PURPOSE: This study examined whether online program exposure (in both an online tailored intervention and an online health education comparison program) predicted greater retention among African American youth and their parents in the Families Improving Together (FIT) for Weight Loss trial. METHODS: Parent-adolescent dyads (N = 125) were randomized to either an online tailored intervention program (n = 63) or an online health education comparison program (n = 62). Paradata including login data were used to determine the number of sessions viewed (0-8) and the number of minutes spent online per session. Study retention, defined as collection of adolescent anthropometric measures at 6 months postintervention, was the outcome. RESULTS: Logistic regression analyses showed a significant effect for login rate on retention (OR = 1.21, 95% CI [1.04, 1.39]). Total number of sessions viewed, child age, child sex, parent age, and parent sex accounted for 11% of the variance in retention at 6 months post- intervention. Participants who were retained spent a significantly greater number of minutes during each session (M = 12.99, SD = 11.63) than participants who were not retained (M = 7.77, SD = 11.19), t(123) = 2.24, p = .027, d = 0.45. CONCLUSIONS: The use of paradata from online interventions is a novel and feasible approach for examining exposure in web-based interventions and program retention in underserved ethnic minority families. TRIAL REGISTRATION: ClinicalTrials.gov NCT01796067. Registered January 23, 2013.