Implementing an Evidence-based Tobacco Control Program at Five 2-1-1 Call Centers: An Evaluation Using the Consolidated Framework for Implementation Research.

Introduction: The Smoke-Free Homes (SFH) Program is an evidence-based intervention offered within 2-1-1 information and referral call centers to promote smoke-free homes in low-income populations. We used the Consolidated Framework for Implementation Research to conduct a mixed-methods analysis of facilitators and barriers to scaling up SFH to five 2-1-1 sites in the United States. Methods: Data were collected from staff in 2015-2016 via online surveys administered before (N = 120) and after SFH training (N = 101) and after SFH implementation (N = 79). Semi-structured telephone interviews were conducted in 2016 with 25 staff to examine attitudes towards SFH, ways local context affected implementation, and unintended benefits and consequences of implementing SFH. Results: Post-implementation, 79% of respondents reported that SFH was consistent with their 2-1-1's mission, 70% thought it led to more smoke-free homes in their population, 62% thought it was easy to adapt, and 56% thought participants were satisfied. Composite measures of perceived appropriateness of SFH for 2-1-1 callers and staff positivity toward SFH were significantly lower post-implementation than pre-implementation. In interviews, staff said SFH fit with their 2-1-1's mission but expressed concerns about intervention sustainability, time and resources needed for delivery, and how SFH fit into their workflow. Conclusions: Sites' SFH implementation experiences were affected both by demands of intervention delivery and by SFH's perceived effectiveness and fit with organizational mission. Future implementation of SFH and other tobacco control programs should address identified barriers by securing ongoing funding, providing dedicated staff time, and ensuring programs fit with staff workflow. Implications: Smoke-free home policies reduce exposure to secondhand smoke. Partnering with social service agencies offers a promising way to scale up evidence-based smoke-free home interventions among low-income populations. We found that the SFH intervention was acceptable and feasible among multiple 2-1-1 delivery sites. There were also significant challenges to implementation, including site workflow, desire to adapt the intervention, time needed for intervention delivery, and financial sustainability. Addressing such challenges will aid future efforts to scale up evidence-based tobacco control interventions to social service agencies such as 2-1-1.

African American's self-report patterns using the National Cancer Institute Colorectal Cancer Screening questionnaire.

Studies that examine colorectal cancer screening (CRCS) behaviors and correlates rely on self-reports of screening status. Self-reports of CRCS may be more biased than other self-reported cancer screening because of multiple screening options, tests may be offered in combination, and screening schedules differ for each test. The National Cancer Institute (NCI) sponsored the development of a core set of questions to measure self-reported CRCS that are consistent with current guidelines, the NCI Colorectal Cancer Screening questionnaire (NCI CRCS). Several studies support the validity and reliability of this measure; however, none of the existing studies have described African American (AA) responses to items that might be important to clinical decision making and research related to screening adherence. This paper addresses the limited descriptions of AA response patterns to items that comprise the NCI CRCS. The NCI CRCS was administered to 439 AAs 50 to 75 years, participating in the baseline survey of a Center for Excellence in Cancer Communication CRC study. The survey measured self-reported CRCS, factors associated with screening, and response patterns to items that might affect estimates of screening and screening adherence. AA participants reported on CRCS, the test used, and time interval since last screening. Except for queries related to month and year of screening, few participants reported uncertainty in response to items. Two thirds of participants reported receiving CRCS; however, less than half of participants were adherent to guidelines. Less than half reported healthcare provider recommendations to screen. AA participants responded to items on the NCI CRCS as developed. Until new strategies or items are available, interval since last screening appears to be the most appropriate item to estimate AA self-reported CRCS adherence. Strategies are needed to increase physician recommendation to screen.

Social Needs and Health-Related Outcomes Among Medicaid Beneficiaries.

Unmet social needs-including food, housing, and utilities-have been associated with negative health outcomes, but most prior research has examined the health associations with a single unmet need or analyzed samples that were homogeneous along one or more dimensions (e.g., older adults or patients with chronic health conditions). We examined the association between unmet social needs and psychosocial and health-related outcomes in a sample of Medicaid beneficiaries from 35 U.S. states. In 2016-2017, 1,214 people completed an online survey about social needs, demographics, and health-related and psychosocial outcomes. Seven items assessing social needs formed an index in which higher scores indicated higher levels of unmet needs. Participants were eligible if they were ≥18 years and had Medicaid. The sample was predominantly female (87%). Most (71%) lived with at least one child ≤18 years, and 49% were White and 33% were African American. Average age was 36 years ( SD = 13). The most common unmet needs were not enough money for unexpected expenses (54%) and not enough space in the home (25%). Analyses controlling for recruitment method and demographics showed that increasing levels of unmet social needs were positively associated with stress, smoking, and number of chronic conditions, and negatively associated with future orientation, attitudes toward prevention, days of exercise/week, servings of fruits or vegetables/day, and self-rated health (all p < .01). Results add to the evidence about the relationship between unmet social needs and health. Interventions to help meet social needs may help low-income people improve both their economic situations and their health.

Applying projective techniques to formative research in health communication development.

This article describes a new approach to formative research in which projective techniques commonly used in psychological assessment were adapted for use in focus groups to help design colorectal-cancer screening materials for African American men and women. Participants (N = 20) were divided into six "design teams." Each team was given a selection of design supplies and asked to create and discuss a visual layout for screening materials. Participants chose design elements that reflected visual preferences that they felt would connect meaningfully with other African Americans. The dynamics within the design teams were different than in traditional focus groups, with participants having more control over the group's direction. Using projective techniques helped draw out unique information from participants by allowing them to "project" their opinions onto objects. This approach may be a valuable tool for health-promotion and health-communication practitioners seeking insight on the implicit values of a priority population.

A community-based approach to promoting walking in rural areas.

BACKGROUND: Ecologic models are often recommended to promote physical activity, yet sparse data exist on their effectiveness. DESIGN: A quasi-experimental design examined changes in walking behavior in six rural intervention communities in the Missouri "bootheel" region and in six comparison communities in Arkansas and Tennessee. SETTING/ PARTICIPANTS: The communities ranged in population from 2399 to 17,642; interventions focused on adults aged >/=18 years. INTERVENTION: Interventions were developed with community input and included individually tailored newsletters, interpersonal activities that stressed social support, and community-wide events such as walk-a-thons. MAIN OUTCOME MEASURES: Primary outcomes were rates of walking-trail use, total number of minutes walked in the past week, and total minutes walked for exercise. RESULTS: Among persons who used trails at baseline (16.9% of the total population), 32.1% reported increases in physical activity since they began using the trail. From community-wide samples, two subgroups indicated a positive net change in rates of 7-day total walking: people with high school degrees or less and people living in households with annual incomes of <==$20,000. However, no studied group showed a statistically significant net intervention effect. CONCLUSIONS: Although there was an increase in the rate of walking-trail use, a community-wide change in walking rates in rural communities was not documented. Results of this study should provide guidance for future projects.

The use of mentoring programs to improve energy balance behaviors in high-risk children.

This study tested the impact of a multicomponent intervention entitled "Partners of all Ages Reading About Diet and Exercise" (PARADE) a child-focused energy balance intervention incorporated into mentoring programs. We used a group randomized nested cohort design randomizing mentoring program sites (n = 119) and children (N = 782; females = 49%; African American = 37%; mean (s.d.) age = 8.5 (1.5) years) to intervention or usual care conditions. PARADE mentors delivered eight lesson plans addressing key concepts related to diet and activity; eight child-focused computer-tailored storybooks with messages targeting that child's diet and activity patterns and eight parent action support newsletters. When compared to the control group, PARADE children were more knowledgeable of diet and activity guidelines (P < 0.01), challenged themselves more to eat five fruits and vegetables (FV) (P < 0.01) and be active 1 h daily (P < 0.01), and to ask for FV for snack (P = 0.015). Calories from high fat foods decreased in overweight/obese children, but not for normal weight children (P = 0.059). There were no significant differences in fruit and vegetable intake, total calories, percent time being active, or BMI z-score. The combination of one-to-one mentoring, child-focused computer based tailoring, and parent support may impact important behavioral change precursors in environments over which the child has control, especially among normal weight children. Further, work is needed to evaluate the impact of family-focused multicomponent interventions, including computer-tailored approaches, directed toward both the parent and the child.

Comparing the use of evidence and culture in targeted colorectal cancer communication for African Americans.

OBJECTIVE: This study examined the effects (affective reactions, cognitive reactions and processing, perceived benefits and barriers and intent to screen) of targeted peripheral+evidential (PE) and peripheral+evidential+socio-cultural (PE+SC) colorectal cancer communications. METHODS: This study was a two-arm randomized control study of cancer communication effects on affective, cognitive processing, and behavioral outcomes over a 22-week intervention. There were 771 African American participants, 45-75 years, participating in the baseline survey related to CRC screening. Three follow-up interviews that assessed intervention effects on affective response to the publications, cognitive processing, and intent to obtain CRC screening were completed. RESULTS: There were no statistically significant differences between PE and PE+SC intervention groups for affect, cognitive processing or intent to screen. However, there were significant interactions effects on outcome variables. CONCLUSIONS: The advantages and disadvantages of PE+SC targeted cancer communications and implications of sex differences are considered. PRACTICE IMPLICATIONS: While there do not appear to be significant differences in behavioral outcomes when using PE and PE+SC strategies, there appear to be subtle differences in affective and cognitive processing outcomes related to medical suspicion and ethnic identity, particularly as it relates to gender.

High 5 for Kids: the impact of a home visiting program on fruit and vegetable intake of parents and their preschool children.

OBJECTIVE: The High 5 for Preschool Kids (H5-KIDS) program tested the effectiveness of a home based intervention to teach parents how to ensure a positive fruit-vegetable (FV) environment for their preschool child, and to examine whether changes in parent behavior were associated with improvements in child intake. METHODS: A group randomized nested cohort design was conducted (2001 to 2006) in rural, southeast Missouri with 1306 parents and their children participating in Parents As Teachers, a national parent education program. RESULTS: When compared to control parents, H5-KIDS parents reported an increase in FV servings (MN=0.20, p=0.05), knowledge and availability of FV within the home (p=0.01), and decreased their use of noncoercive feeding practices (p=0.02). Among preschoolers, FV servings increased in normal weight (MN=0.35, p=0.02) but not overweight children (MN=-0.10, p=0.48), relative to controls. The parent's change in FV servings was a significant predictor of child's change in FV in the H5-KIDS group (p=0.001). CONCLUSION: H5-KIDS suggests the need for, and promise of, early home intervention for childhood obesity prevention. It demonstrates the importance of participatory approaches in developing externally valid interventions, with the potential for dissemination across national parent education programs as a means for improving the intake of parents and young children.

A multilevel ecological approach to promoting walking in rural communities.

BACKGROUND: Walking is a key focus of public health interventions yet is particularly uncommon in rural residents. This study's purpose was to determine whether a multilevel community intervention affected rates of moderate physical activity, in particular walking. METHODS: A quasi-experimental design examined changes in walking in six rural intervention communities in Missouri and six comparison communities in Arkansas and Tennessee in 2003-2004. Interventions were developed with community input and included individually tailored newsletters; interpersonal activities that stressed social support and health provider counseling; and community-wide events such as fun walks. A dose variable estimated exposure to intervention activities. Primary outcomes were rates of walking and moderate physical activity in the past week. RESULTS: At follow-up (n = 1531), the percentage of respondents who met the recommendation for walking was the same across the intervention and comparison areas. Among the dependent variables, walking showed some evidence of a positive linear trend across dose categories (P = 0.090). After adjusting for covariates and baseline rates, intervention participants in the moderate and high dose categories were about three times more likely to meet recommended guidelines for walking. CONCLUSIONS: Some evidence of effectiveness was shown for a multilevel intervention approach to promote walking.