Implementation of tobacco cessation brief intervention in complementary and alternative medicine practice: qualitative evaluation.

BACKGROUND: This article presents findings from qualitative interviews conducted as part of a research study that trained Acupuncture, Massage, and Chiropractic practitioners' in Arizona, US, to implement evidence-based tobacco cessation brief interventions (BI) in their routine practice. The qualitative phase of the overall study aimed to assess: the impact of tailored training in evidence-based tobacco cessation BI on complementary and alternative medicine (CAM) practitioners' knowledge and willingness to implement BIs in their routine practice; and their patients' responses to cessation intervention in CAM context. METHODS: To evaluate the implementation of skills learned from a tailored training program, we conducted semi-structured qualitative interviews with 54 CAM practitioners in Southern Arizona and 38 of their patients. Interview questions focused on reactions to the implementation of tobacco cessation BIs in CAM practice. RESULTS: After participating in a tailored BI training, CAM practitioners reported increased confidence, knowledge, and motivation to address tobacco in their routine practice. Patients were open to being approached by CAM practitioners about tobacco use and viewed BIs as an expected part of wellness care. CONCLUSIONS: Tailored training motivated CAM practitioners in this study to implement evidence-based tobacco cessation BIs in their routine practice. Results suggest that CAM practitioners can be a valuable point of contact and should be included in tobacco cessation efforts.

Ways of Hoping: Navigating the Paradox of Hope and Despair in Chronic Pain.

In this paper, we explore hope in the context of living with chronic pain. Individuals with chronic pain from temporomandibular disorder(s) were interviewed four to five times over the course of their 18-month participation in a clinical trial investigating the effectiveness of Traditional Chinese Medicine. We sought to understand shifts in participants' descriptions of expectations and hopefulness, particularly with regard to the work involved in counterbalancing positive thinking with buffers against disappointment. We found hope to be a dynamic and multifaceted mindset as distinct from being a single entity to be measured. Drawing upon Polanyi's concept of tacit knowing, we explore how different ways of hoping emerge and index one another in participant narratives. We offer a working typology of hope and raise as an issue the manner in which the paradox of hope--hoping enough to carry on while keeping hopes in check to avoid the ever-present possibility of despair--complicates simplistic notions of the relationship between positive thinking and the placebo response.

Printed Educational Materials' Impact on Tobacco Cessation Brief Interventions in CAM Practice: Patient and Practitioner Experiences.

Printed educational materials (PEMs) have long demonstrated their usefulness as economical and effective media for health communication. In this article, we evaluate the impact of targeted tobacco cessation PEMS for use along with a brief intervention training designed for three types of complementary and alternative medicine (CAM) practitioners: chiropractic, acupuncture, and massage. We describe how PEMs in CAM practitioners' offices were perceived and used by practitioners and by patients. Semistructured qualitative interviews were conducted with 53 practitioners and 38 of their patients. This analysis specifically focused on developing and distributing project-related posters and pamphlets in CAM practice. Our findings indicate that materials (1) legitimated tobacco-related expertise among CAM practitioners and tobacco-related conversations as part of routine CAM practice, (2) increased practitioners' willingness to approach the topic of tobacco with patients, (3) created an effective way to communicate tobacco-related information and broaden the reach of brief intervention initiatives, and (4) were given to patients who were not willing to engage in direct discussion of tobacco use with practitioners.

A qualitative study of changes in expectations over time among patients with chronic low back pain seeking four CAM therapies.

BACKGROUND: The relationship between patient expectations about a treatment and the treatment outcomes, particularly for Complementary and Alternative Medicine (CAM) therapies, is not well understood. Using qualitative data from a larger study to develop a valid expectancy questionnaire for use with participants starting new CAM therapies, we examined how participants' expectations of treatment changed over the course of a therapy. METHODS: We conducted semi-structured qualitative interviews with 64 participants initiating one of four CAM therapies (yoga, chiropractic, acupuncture, massage) for chronic low back pain. Participants just starting treatment were interviewed up to three times over a period of 3 months. Interviews were transcribed verbatim and analyzed using a qualitative mixed methods approach incorporating immersion/crystallization and matrix analysis for a decontexualization and recontextualization approach to understand changes in thematic emphasis over time. RESULTS: Pre-treatment expectations consisted of conjecture about whether or not the CAM therapy could relieve pain and improve participation in meaningful activities. Expectations tended to shift over the course of treatment to be more inclusive of broader lifestyle factors, the need for long-term pain management strategies and attention to long-term quality of life and wellness. Although a shift toward greater acceptance of chronic pain and the need for strategies to keep pain from flaring was observed across participants regardless of therapy, participants varied in their assessments of whether increased awareness of the need for ongoing self-care and maintenance strategies was considered a "positive outcome". Regardless of how participants evaluated the outcome of treatment, participants from all four therapies reported increased awareness, acceptance of the chronic nature of pain, and attention to the need to take responsibility for their own health. CONCLUSIONS: The shift in treatment expectations to greater acceptance of pain and the need for continued self-care suggests that future research should explore how CAM practitioners can capitalize on these shifts to encourage feelings of empowerment rather than disappointment surrounding realizations of the need for continued engagement with self-care.

Works of Illness and the Challenges of Social Risk and the Specter of Pain in the Lived Experience of TMD.

Temporomandibular Disorders (TMD) represent a particular form of chronic pain that, while not outwardly debilitating, profoundly impacts interactions as fundamental to human existence as smiling, laughing, speaking, eating, and intimacy. Our analysis, informed by an expanded "works of illness" assessment, draws attention to work surrounding social and physical risk. We refer to these as the work of stoicism and the work of vigilance and identify double binds created in contexts that call for both. Conflicting authorial stances in informants' narratives are shown to be essential in maintaining a positive identity in the face of illness. While earlier ethnographic studies report TMD sufferers' experience of stigma and search for diagnosis and legitimacy, we present a group of individuals who have accepted diagnosis at face value and soldier through pain as a fundamental aspect of their identity.

Cognitive interviews guide design of a new CAM patient expectations questionnaire.

BACKGROUND: No consistent relationship exists between pre-treatment expectations and therapeutic benefit from various complementary and alternative medicine (CAM) therapies in clinical trials. However, many different expectancy measures have been used in those studies, with no validated questionnaires clearly focused on CAM and pain. We undertook cognitive interviews as part of a process to develop and validate such a questionnaire. METHODS: We reviewed questions about expectations of benefits of acupuncture, chiropractic, massage, or yoga for pain. Components of the questions - verbs, nouns, response options, terms and phrases describing back pain - were identified. Using seven different cognitive interview scripts, we conducted 39 interviews to evaluate how individuals with chronic low back pain understood these individual components in the context of expectancy questions for a therapy they had not yet received. Chosen items were those with the greatest agreement and least confusion among participants, and were closest to the meanings intended by the investigators. RESULTS: The questionnaire drafted for psychometric evaluation had 18 items covering various domains of expectancy. "Back pain" was the most consistently interpreted descriptor for this condition. The most understandable response options were 0-10 scales, a structure used throughout the questionnaire, with 0 always indicating no change, and 10 anchored with an absolute descriptor such as "complete relief". The use of words to describe midpoints was found to be confusing. The word "expect" held different and shifting meanings for participants. Thus paired items comparing "hope" and "realistically expect" were chosen to evaluate 5 different aspects of treatment expectations (back pain; back dysfunction and global effects; impact of back pain on specific areas of life; sleep, mood, and energy; coping). "Impact of back pain" on various areas of life was found to be a consistently meaningful concept, and more global than "interference". CONCLUSIONS: Cognitive interviews identified wordings with considerable agreement among both participants and investigators. Some items widely used in clinical studies had different meanings to participants than investigators, or were confusing to participants. The final 18-item questionnaire is undergoing psychometric evaluation with goals of streamlining as well as identifying best items for use when questionnaire length is constrained.

New perspectives on patient expectations of treatment outcomes: results from qualitative interviews with patients seeking complementary and alternative medicine treatments for chronic low back pain.

BACKGROUND: Positive patient expectations are often believed to be associated with greater benefits from complementary and alternative medicine (CAM) treatments. However, clinical studies of CAM treatments for chronic pain have not consistently supported this assumption, possibly because of differences in definitions and measures of expectations. The goal of this qualitative paper is to provide new perspectives on the outcome expectations of patients prior to receiving CAM therapies for chronic low back pain. METHODS: We conducted semi-structured interviews with 64 individuals receiving massage, chiropractic, acupuncture or yoga for chronic low back pain. Interviews were recorded and transcribed. Transcripts were analyzed by a team of experienced qualitative researchers using an immersion/crystallization approach to coding and analysis. RESULTS: Overall, participants' expectations of treatment outcomes tended to cluster in four key domains: pain relief, improved function (including an increase in ability to engage in meaningful activities), improved physical fitness, and improved overall well-being (including mental well-being). Typically, patients had modest expectations for outcomes from treatment. Furthermore, outcome expectations were complex on several levels. First, the concept of expectations overlapped with several related concepts; in particular, hopes. Participants sometimes used expectations and hopes interchangeably and at other times made clear distinctions between these two terms depending on context. A related finding was that participants were cautious about stating that they expected positive outcomes. Finally, participants articulated strong interrelationships among the four key domains and often discussed how changes in one domain might affect other domains. CONCLUSIONS: Overall, these findings contribute to a growing body of literature exploring the role of expectations in patient outcomes. This paper provides important guidance that may help refine the way treatment expectations are studied in the future. In particular, participants' statements indicate that standardized measures of patient expectations should include items that capture hesitancy to articulate overly optimistic outcomes as well as interrelationships among different outcomes.

Applying User-Centered Design in the Development of a Supportive mHealth App for Women in Substance Use Recovery.

PURPOSE AND APPROACH: Women in recovery describe stigma, negative treatment, and limited support as barriers to achieving their health and parenting goals. Mobile health technologies carefully tailored to support the unique needs of recovery communities can provide less burdensome alternatives to in-person services for women transitioning out of substance use treatment. An iterative design process integrated women's interests into the structure, content, and interaction flow of a mobile health (mHealth) app. SETTING AND PARTICIPANTS: Participants included women in recovery from opioid, alcohol, and polysubstance use disorders in a comprehensive housing program in urban Arizona. METHODS: Five focus groups with 3-7 participants each (n = 27 total) informed creation of the mHealth app. Informed by theoretical models of usability and person-centered design, development involved an iterative series of focus groups in which we asked women to comment on interest in using each feature. This provided a qualitative priority framework for feature development. We then modified the app and repeated the process to gauge consensus and continually refine our prototype. RESULTS: Women were interested in access to resources, such as housing, counseling, and parenting advice in settings known to treat women in recovery with respect. They also asked for positive messages, chatting with peers, and access to expert answers. They were less interested in points-based learning modules and "scored" activities, leading us to develop a "daily challenges" concept that builds good habits, but does not feel like "classwork". Women's recommendations shaped an mHealth app tailored to maximize utility, access, and safety for this at-risk population. CONCLUSION: Integration of user-centered design with applied ethnographic techniques guided the development of a custom-tailored mHealth app responsive to lived experiences and needs of women in recovery. Future research should evaluate the potential for user-centered apps to increase self-efficacy, perceived social support, and to reduce risk of relapse.

A Qualitative Exploration of Pregnancy Experience With a Nutrient-Dense, Plant-Rich Dietary Pattern: A Pilot Study.

INTRODUCTION: A nutrient-dense, plant-rich diet may be promising as a nutrition intervention for pregnant women for a number of factors. Factors include the possibility of a decreased risk for gestational diabetes, excess weight gain, and preeclampsia. Little is known about the experience of following this type of dietary pattern while pregnant and what barriers are present that should be addressed in a large-scale intervention. METHODS: Qualitative interviews were used to understand the personal experience of women who aimed to eat a nutrient-dense plant-rich diet while pregnant. Semi-structured interviews were conducted from June to August 2020. RESULTS: Three main themes regarding a nutrient-dense plant-rich diet emerged. First, family and social influence played an important role. Second, women who had a previous pregnancy felt they had fewer pregnancy symptoms on this diet. Last, the participants may have experienced a reduced milk supply on this dietary plan. CONCLUSION: Future research should consider family context as a factor in adherence to a nutrient-dense plant-rich dietary pattern, investigate the possible associations between nutrient-dense plant-rich dietary patterns and reduced nausea and vomiting in early pregnancy, and determine whether nutrient-dense, plant-rich dietary patterns contribute to a reduction in milk production for women who experience over-engorgement.

Possibilities and constraints of rapid online ethnography: Lessons from a rapid assessment of COVID-19 policy for people who use drugs.

During the COVID-19 Pandemic, health care provision changed rapidly and funding became available to assess pandemic-related policy change. Research activities, however, were limited to contactless, online delivery. It was clear early on that some elements of online rapid ethnography were feasible and effective, while others would not approach traditional ethnographic depth. We conducted an online Rapid Assessment, Response, and Evaluation (RARE) project from August 2020 to September 2021 to understand how COVID-19 policy impacted people who use drugs. Our interdisciplinary research team conducted online ethnographic interviews and focus groups with 45 providers and community stakeholders, and 19 clients from rural and urban areas throughout Arizona. In addition, 26 webinars, online trainings, and virtual conferences focused on opioid policy and medication for opioid use disorders (MOUD) were opportunities to observe conversations among providers and program representatives about how best to implement policy changes, how to reach people in recovery, and what aspects of the changes should carry forward into better all-around opioid services in the future. Our RARE project was successful in collecting a range of providers' perspectives on both rural and urban implementation of take-home MOUDs as well as a wide view of national conversations, but client perspectives were limited to those who were not impacted by the policies and continued to attend in-person daily clinic visits. We describe challenges to online rapid ethnography and how online research may have allowed for an in-depth, but incomplete picture of how policy changes during COVID-19 policy affected people with opioid use disorders.

Adverse Childhood Experiences in relation to drug and alcohol use in the 30 days prior to incarceration in a county jail.

Purpose: To characterize the relationship between adverse childhood experiences (ACEs) and substance use among people incarcerated in a county jail. Design/methodology/approach: A questionnaire was administered to 199 individuals incarcerated in a Southwest county jail as part of a social-epidemiological exploration of converging co-morbidities in incarcerated populations. Among 96 participants with complete ACEs data, the authors determined associations between individual ACEs items and a summative score with methamphetamine (meth), heroin, other opiates, and cocaine use and binge drinking in the 30 days prior to incarceration using logistic regression. Findings: People who self-reported use of methamphetamine, heroin, other opiates, or cocaine in the 30 days prior to incarceration had higher average ACEs scores. Methamphetamine use was significantly associated with living with anyone who served time in a correctional facility and with someone trying to make them touch sexually. Opiate use was significantly associated with living with anyone who was depressed, mentally ill, or suicidal; living with anyone who used illegal street drugs or misused prescription medications; and if an adult touched them sexually. Binge drinking was significantly associated with having lived with someone who was a problem drinker or alcoholic. Originality: Significant associations between methamphetamine use and opiate use and specific adverse childhood experiences suggest important entry points for improving jail and community programming. Social Implications: Our findings point to a need for research to understand differences between methamphetamine use and opiate use in relation to particular adverse experiences during childhood, and a need for tailored intervention for people incarcerated in jail.

Characterization of neonatal opioid withdrawal syndrome in Arizona from 2010-2017.

In this paper, we describe a population of mothers who are opioid dependent at the time of giving birth and neonates exposed to opioids in utero who experience withdrawal following birth. While there have been studies of national trends in this population, there remains a gap in studies of regional trends. Using data from the Arizona Department of Health Services Hospital Discharge Database, this study aimed to characterize the population of neonates with neonatal opioid withdrawal syndrome (NOWS) and mothers who were opioid dependent at the time of giving birth, in Arizona. We analyzed approximately 1.2 million electronic medical records from the Arizona Department of Health Services Hospital Discharge Database to identify patterns and disparities across socioeconomic, ethnic, racial, and/or geographic groupings. In addition, we identified comorbid conditions that are differentially associated with NOWS in neonates or opioid dependence in mothers. Our analysis was designed to assess whether indicators such as race/ethnicity, insurance payer, marital status, and comorbidities are related to the use of opioids while pregnant. Our findings suggest that women and neonates who are non-Hispanic White and economically disadvantaged, tend be part of our populations of interest more frequently than expected. Additionally, women who are opioid dependent at the time of giving birth are unmarried more often than expected, and we suggest that marital status could be a proxy for support. Finally, we identified comorbidities associated with neonates who have NOWS and mothers who are opioid dependent not previously reported.

"Alcohol is something that been with us like a common cold": community perceptions of American Indian drinking.

This study examined tribal members' perspectives on alcohol, risk factors, consequences, and community responses. Focus groups were conducted with five American Indian tribes between 1997 and 2001. Participants were knowledgeable of the cultural lives of their reservation communities. Although there was agreement regarding the pervasiveness of heavy drinking, participants reported different opinions about the meaning of alcohol and appropriate intervention strategies. Three dilemmas were identified, suggesting that community ambivalence may serve as a barrier to reducing problem drinking. Implications, limitations, and future research directions are discussed. The study was funded by the National Institute on Alcohol Abuse and Alcoholism.

Integrating Behavioral and Primary Health Care in Rural Clinics: What Does Culture Have to Do with It?

Successful integration of health care in rural and underserved communities requires attention to power structures, trust, and disciplinary boundaries that inhibit team-based integration of behavioral and primary health care. This paper reports on perceived successes and ongoing challenges of integrating primary and behavioral health care from the perspectives of providers, community leaders, and community members. Data collection consisted of semi-structured qualitative interviews and focus groups conducted as part of a regional health equity assessment in northern Arizona. The authors explore barriers and successes in integrating health care in rural clinics using the perspective of a social ecological framework and the mediating role of culture. Differing expectations, differing professional areas, and interpersonal interactions were primary factors challenging movement toward integrated health care. Results suggest that providers and policymakers working toward health care integration should consider culture and interpersonal interaction as dynamic mediators, particularly in underserved and rural health care contexts.

Whole Systems Within Whole Systems: The Oregon Health Plan's Expansion of Services for Back and Neck Pain.

OBJECTIVES: The authors employ a Whole Systems framework to explore implementation of new guidelines for back and neck pain in Oregon's Medicaid system. Whole Systems research is useful for understanding the relationship between complementary and integrative health care (CIH) and conventional health care systems in real-world clinical and practice settings. DESIGN: Preliminary results are from an observational study designed to evaluate state-wide implementation of CIH and other non-pharmacological treatments for neck and back pain among Oregon Medicaid patients. This natural experiment, even in early stages, provides insight into the challenges of integrating Whole Systems oriented therapies into Medicaid billing and treatment. METHODS: Qualitative data are drawn from: (1) semi-structured interviews with representatives of each of the 16 coordinated care organizations (CCOs) responsible for administering the Oregon's Medicaid insurance through the Oregon Health Plan (OHP); and (2) open-ended survey responses from acupuncturists in all 16 CCO areas. RESULTS: Implementation of the new policy guidelines poses logistical and epistemological challenges. Differences in worldview, inadequate reimbursement, and simple lack of awareness of CIH among medical providers are some of the factors that pose barriers to merging CIH therapies into conventional frameworks. CONCLUSIONS: In this article, we explore the potential for a Whole Systems perspective to better explain the complexity of integrating CIH and other non-pharmacological services into a state financed health care system. Oregon's expansion of services for back and neck pain presents an opportunity to explore challenges and successes in melding multiple approaches to health and pain management into a managed system such as the OHP.

Health disparities in jail populations: Mixed methods and multi-disciplinary community engagement for justice and health impacts.

This special issue of Practicing Anthropology presents multidisciplinary and multisectoral views of a community engaged health disparities project titled "Health Disparities in Jail Populations: Converging Epidemics of Infectious Disease, Chronic Illness, Behavioral Health, and Substance Abuse." The overall project incorporated traditional anthropological mixed-methods approaches with theory and methods from informatics, epidemiology, genomics, evolutionary and computational biology, community engagement, and applied/translational science.

Health Disparities and Converging Epidemics in Jail Populations: Protocol for a Mixed-Methods Study.

BACKGROUND: Incarcerated populations have increased in the last 20 years and >12 million individuals cycle in and out of jails each year. Previous research has predominately focused on the prison population. However, a substantial gap exists in understanding the health, well-being, and health care utilization patterns in jail populations. OBJECTIVE: This pilot study has 5 main objectives: (1) define recidivists of the jail system, individuals characterized by high incarceration rates; (2) describe and compare the demographic and clinical characteristics of incarcerated individuals; (3) identify jail-associated health disparities; (4) estimate associations between incarceration and health; and (5) describe model patterns in health care and jail utilization. METHODS: The project has two processes-a secondary data analysis and primary data collection-which includes a cross-sectional health survey and biological sample collection to investigate infectious disease characteristics of the jail population. This protocol contains pilot elements in four areas: (1) instrument validity and reliability; (2) individual item assessment; (3) proof of concept of content and database accessibility; and (4) pilot test of the "honest broker" system. Secondary data analysis includes the analysis of 6 distinct databases, each covered by a formal memorandum of agreement between Northern Arizona University and the designated institution: (1) the Superior Court of Arizona Public Case Finder database; (2) North Country Health Care; (3) Health Choice Integrated Care; (4) Criminal Justice Information Services; (5) Correctional Electronic Medical Records; and (6) iLEADS. We will perform data integration processes using an automated honest broker design. We will administer a cross-sectional health survey, which includes questions about health status, health history, health care utilization, substance use practices, physical activity, adverse childhood events, and behavioral health, among 200 Coconino County Detention Facility inmates. Concurrent with the survey administration, we will collect Methicillin-resistant and Methicillin-sensitive Staphylococcus aureus (samples from the nose) and dental microbiome (Streptococcus sobrinus and Streptococcus mutans samples from the mouth) from consenting participants. RESULTS: To date, we have permission to link data across acquired databases. We have initiated data transfer, protection, and initial assessment of the 6 secondary databases. Of 199 inmates consented and enrolled, we have permission from 97.0% (193/199) to access and link electronic medical and incarceration records to their survey responses, and 95.0% (189/199) of interviewed inmates have given nasal and buccal swabs for analysis of S. aureus and the dental microbiome. CONCLUSIONS: This study is designed to increase the understanding of health needs and health care utilization patterns among jail populations, with a special emphasis on frequently incarcerated individuals. Our findings will help identify intervention points throughout the criminal justice and health care systems to improve health and reduce health disparities among jail inmates. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR1-10.2196/10337.

Broadening measures of success: results of a behavioral health translational research training program.

BACKGROUND: While some research training programs have considered the importance of mentoring in inspiring professionals to engage in translational research, most evaluations emphasize outcomes specific to academic productivity as primary measures of training program success. The impact of such training or mentoring programs on stakeholders and local community organizations engaged in translational research efforts has received little attention. The purpose of this evaluation is to explore outcomes other than traditional academic productivity in a translational research graduate certificate program designed to pair graduate students and behavioral health professionals in collaborative service-learning projects. METHODS: Semi-structured qualitative interviews with scholars, community mentors, and academic mentors were conducted regarding a translational research program to identify programmatic impacts. Interviews were transcribed and coded by the research team to identify salient themes related to programmatic outcomes. RESULTS: Results are framed using the Translational Research Impact Scale which is organized into three overarching domains of potential impact: (1) research-related impacts, (2) translational impacts, and (3) societal impacts. This evaluation demonstrates the program's impact in all three domains of the TRIS evaluation framework. Graduate certificate participants (scholars) reported that gaining experience in applied behavioral health settings added useful skills and expertise to their present careers and increased their interest in pursuing translational research. Scholars also described benefits resulting from networks gained through participation in the program, including valuable ties between the university and community behavioral health organizations. CONCLUSIONS: This evaluation of the outcomes of a graduate certificate program providing training in translational research highlights the need for more community-oriented and practice-based measures of success. Encouraging practitioner involvement in translational research is vital to translate knowledge into practice and to enable practice-based needs to inform research and policy. A more flexible approach to measuring programmatic success in research training programs can help bridge the knowledge translation gap.

Demographic Trends in Utah College Students' Vigorous Physical Activity, 2003-2007.

OBJECTIVES: This analysis of a large-scale survey of college students from 2003 to 2007 explores relationships between meeting vigorous physical activity (VPA) recommendations and key demographic, lifestyle, and personal characteristics. METHODS: Multivariate logistic regression modeling was used to analyze VPA data from the Utah Higher Education Health Behavior Survey, a descriptive cross-sectional survey conducted in 2003 (N = 4574), 2005 (N = 9673) and 2007 (N = 7938). RESULTS: Factors consistently associated with meeting VPA recommendations included involvement in extracurricular sports, being single, and daily consumption of fruits or vegetables. In contrast, factors such as older age (> 23 years old), having a particularly low (<18.5 kg˙m2) or high BMI (> 34.9 kg˙m2), and being a current smoker were associated with not meeting the VPA recommendation. This corroborates paradoxical findings that binge alcohol consumption correlates with meeting VPA. CONCLUSIONS: Findings support the need for targeted interventions among college students to support the establishment of long-term protective behavioral patterns against chronic disease risk throughout the life course.

Online Tobacco Cessation Training and Competency Assessment for Complementary and Alternative Medicine (CAM) Practitioners: Protocol for the CAM Reach Web Study.

BACKGROUND: Complementary and alternative medicine (CAM) practitioners, such as chiropractors, acupuncturists, and massage therapists, are a growing presence in the US health care landscape and already provide health and wellness care to significant numbers of patients who use tobacco. For decades, conventional biomedical practitioners have received training to provide evidence-based tobacco cessation brief interventions (BIs) and referrals to cessation services as part of routine clinical care, whereas CAM practitioners have been largely overlooked for BI training. Web-based training has clear potential to meet large-scale training dissemination needs. However, despite the exploding use of Web-based training for health professionals, Web-based evaluation of clinical skills competency remains underdeveloped. OBJECTIVE: In pursuit of a long-term goal of helping CAM practitioners integrate evidence-based practices from US Public Health Service Tobacco Dependence Treatment Guideline into routine clinical care, this pilot protocol aims to develop and test a Web-based tobacco cessation training program tailored for CAM practitioners. METHODS: In preparation for a larger trial to examine the effect of training on CAM practitioner clinical practice behaviors around tobacco cessation, this developmental study will (1) adapt an existing in-person tobacco cessation BI training program that is specifically tailored for CAM therapists for delivery via the Internet; (2) develop a novel, Web-based tool to assess CAM practitioner competence in tobacco cessation BI skills, and conduct a pilot validation study comparing the competency assessment tool to live video role plays with a standardized patient; (3) pilot test the Web-based training with 120 CAM practitioners (40 acupuncturists, 40 chiropractors, 40 massage therapists) for usability, accessibility, acceptability, and effects on practitioner knowledge, self-efficacy, and competency with tobacco cessation; and (4) conduct qualitative and quantitative formative research on factors influencing practitioner tobacco cessation clinical behaviors (eg, practice environment, peer social influence, and insurance reimbursement). RESULTS: Web-training and competency assessment tool development and study enrollment and training activities are complete (N=203 practitioners enrolled). Training completion rates were lower than expected (36.9%, 75/203), necessitating over enrollment to ensure a sufficient number of training completers. Follow-up data collection is in progress. Data analysis will begin immediately after data collection is complete. CONCLUSIONS: To realize CAM practitioners' potential to promote tobacco cessation and use of evidence-based treatments, there is a need to know more about the facilitative and inhibitory factors influencing CAM practitioner tobacco intervention behaviors (eg, social influence and insurance reimbursement). Given marked differences between conventional and CAM practitioners, extant knowledge about factors influencing conventional practitioner adoption of tobacco cessation behaviors cannot be confidently extrapolated to CAM practitioners. The potential impact of this study is to expand tobacco cessation and health promotion infrastructure in a new group of health practitioners who can help combat the continuing epidemic of tobacco use.