Community health workers as change agents in improving equity in birth outcomes in Detroit.

We examined whether pairing pregnant women with community health workers improved pregnancy outcomes among 254 Black women with singleton pregnancies participating in the Women-Inspired Neighborhood (WIN) Network: Detroit using a case-control design. A subset (N = 63) of women were recontacted and asked about program satisfaction, opportunities, and health behaviors. Michigan Vital Statistics records were used to ascertain controls (N = 12,030) and pregnancy and infant health outcomes. Logistic and linear regression were used to examine the association between WIN Network participation and pregnancy and infant health outcomes. The WIN Network participants were less likely than controls to be admitted to the neonatal intensive care unit (odds ratio = 0.55, 95% CI 0.33-0.93) and had a longer gestational length (mean difference = 0.42, 95% CI 0.02-0.81). Community health workers also shaped participants' view of opportunities to thrive. This study demonstrates that community health workers can improve pregnancy outcomes for Black women.

Understanding the Impact of Perceived Social Support for Breastfeeding Among African American Women: Results From the Mama Bear Feasibility Trial.

PURPOSE: Perceived Social Support (PSS) can impact breastfeeding behaviors, and a lack of PSS potentially contributes to disparities in breastfeeding rates for African American women (AA). Objectives were to describe PSS at two timepoints and test associations between PSS and breastfeeding intensity for AA. METHODS: Data are from a feasibility trial of breastfeeding support among AA. The Hughes Breastfeeding Support Scale was used to measure PSS (Emotional, Informational, Tangible; total range = 30-120) in pregnancy (T1, n = 32) and early postpartum (T2, n = 31). Scale means were compared with t-tests. Associations between PSS at T1 and breastfeeding intensity (ie, quantitative measure of breastfeeding) were assessed with linear regression. RESULTS: Total PSS (mean ± SE) was high at both time points (T1 = 90.5 ± 4.8; T2 = 92.8 ± 3.1). At T2, older participants or those living with a partner had higher total PSS scores compared to those younger or living alone. Emotional PSS was significantly higher at T2 than T1 with no differences in tangible or informational PSS over time. Mixed-feeding, exclusive breastfeeding, and exclusive formula feeding was distributed at 39%, 32%, and 29%, respectively. Total PSS was not associated with breastfeeding intensity. CONCLUSION: Women reported high levels of social support, and emotional PSS increased over time in this small sample of AA. PSS and sources of PSS are understudied, especially among AA, and future studies should explore quantitative methods to assess PSS. The results of such assessments can then be used to design breastfeeding support interventions.

Breastfeeding Self-Efficacy as a Predictor of Breastfeeding Intensity Among African American Women in the Mama Bear Feasibility Trial.

Background: Improving breastfeeding rates among African American (AA) families is an important public health goal. Breastfeeding self-efficacy, a known predictor of breastfeeding behavior, has seldom been assessed among AAs, in relation to breastfeeding intensity (% breastfeeding relative to total feeding) or as a protective factor in combating the historical breastfeeding challenges faced by people of color. We aimed to test the association between breastfeeding self-efficacy assessed during pregnancy and breastfeeding intensity assessed in the early postpartum period. Methods: This was a secondary data analysis of a randomized controlled feasibility trial of breastfeeding support and postpartum weight management. AA women were recruited during pregnancy from a prenatal clinic in Detroit, MI. Data presented, in this study, were collected at enrollment (n = 50) and ∼6 weeks postpartum (n = 31). Linear regression models were used, adjusting for potential confounders. Results: There were no differences in breastfeeding intensity by study arm; data are from all women with complete data on targeted variables. Age ranged from 18 to 43 years, 52% were Women, Infant's, and Children program enrollees, and 62% had ≥ some college. Breastfeeding self-efficacy during pregnancy was a significant predictor of breastfeeding intensity in the early postpartum period (ß = 0.125, p < 0.05) with only slight attenuation in the fully adjusted model (ß = 0.123, p < 0.05). Implications for Practice: Our results confirm that self-efficacy is an important predictor of breastfeeding practice. Furthermore, the simple act of assessing breastfeeding self-efficacy permits an opportunity for women to reflect on breastfeeding possibilities, and can inform individualized confidence-building interventions to improve the disproportionately low breastfeeding rates among AAs. Clinical Trial Registration number NCT03480048.

Understanding Factors Influencing Breastfeeding Outcomes in a Sample of African American Women.

OBJECTIVES: Persistent disparities in breastfeeding rates among African American (AA) women compared to other population groups have motivated researchers to understand factors influencing breastfeeding choices using a variety of methods. Quantitative surveys are more commonly reported, however, qualitative work that amplifies voices of AA women is limited. METHODS: Participants were recruited from a randomized controlled feasibility trial focused on breastfeeding support for AA women in Detroit, MI. Thirteen women were enrolled in the qualitative portion of the study described here. Using the Socioecological model (SEM) as the theoretical foundation, semi-structured qualitative interviews were conducted to explore perceived facilitators and barriers to breastfeeding. Interviews were digitally recorded, transcribed, and analyzed using Theoretical thematic analysis. RESULTS: Women reported factors ranging from micro to macro SEM levels that discouraged or reinforced breastfeeding. Key challenges included breastfeeding-related discouragement issues, including factors that decreased confidence and led women to terminate breastfeeding (e.g., problems with latching, pumping, lack of comfort with breastfeeding in public, and work constraints). Facilitators included perceived mother and infant benefits, perseverance/commitment/self-motivation, pumping ability, and social support. Participant suggestions for expanding breastfeeding promotion and support included: (1) tangible, immediate, and proactive support; (2) positive non-judgmental support; (3) "milk supply" and "use of pump" education; and (4) self-motivation/willpower/perseverance. CONCLUSIONS FOR PRACTICE: Despite the identification of common facilitators, findings reveal AA women face many obstacles to meeting breastfeeding recommendations. Collaborative discussions between women and healthcare providers focused on suggestions provided by AA women should be encouraged.

Pilot study of a brief provider and EMR-based intervention for overweight teens with asthma.

INTRODUCTION: Asthma-related morbidity is increased in overweight patients, yet providers are given little guidance on how to discuss weight and asthma management with overweight teens. OBJECTIVE: We piloted an electronic medical record (EMR)-based tailored discussion guide (TDG) and a brief provider training, to address weight management in overweight teens with asthma. The primary outcome was intervention impact on patient-reported asthma outcomes (e.g., asthma control and morbidity). Secondary outcomes included change in BMI, patient-centeredness, and change in healthy behaviors. METHODS: Teens aged 13-18 years with persistent asthma and a body mass index ≥ 85th percentile for their age and sex were eligible. Parents of eligible teens were contacted before an upcoming appointment to allow teen enrollment during the clinic visit. Providers reviewed Motivational Interviewing (MI) concepts and were trained in the TDG for support of conversations around weight and asthma management. Measures included asthma outcomes retrieved from the EMR at 6- and 12-month post-baseline, teen impressions of patient-provider communication at 6-week post-enrollment, and teen report of healthy behaviors at 6- and 12-month post-baseline. RESULTS: Of 44 teens enrolled (77% African-American, 63% female), mean BMI for intervention (n=25) and control groups (n=19) at baseline were similar. Thirty participants (68%) completed a 6-week questionnaire. Compared to controls, at 6 months, intervention teens reported fewer days of limited activity and "uncontrolled asthma," but at 12 months, only restricted activity remained lower, and BMI was not reduced. Intervention teens reported clinic visits that were more patient-centered than controls, including discussion of asthma treatment options with provider, feeling ready to follow an asthma treatment routine, and receiving helpful tips about reaching a healthy weight. The healthy behavior "dinner with family" showed improvement for intervention teens at 6 and 12 months. The feasibility study also revealed a need to improve recruitment strategies and to streamline intervention delivery. CONCLUSION: Modest improvements in patient-reported asthma outcomes and health behaviors were observed. There was strong evidence that the TDG supports provider discussion of weight and asthma to create a more patient-centered conversation from the perspective of participating teens. Challenges to recruitment and clinic adaptation must be addressed before advancing to a full-scale trial. TRIAL REGISTRATION: NCT02575326 Teen Asthma Control Encouraging a Healthier Lifestyle, www.cllinicaltrials.gov.

Changes in fruit and vegetable consumption in relation to changes in sleep characteristics over a 3-month period among young adults.

OBJECTIVE: To evaluate whether increases in fruit and vegetable (FV) consumption were associated with concomitant changes in insomnia symptoms, sleep duration, and quality. DESIGN: Secondary longitudinal analysis of a randomized trial, baseline to 3 months. SETTING: Integrated health care systems in Detroit, Michigan and Danville, Pennsylvania. PARTICIPANTS: About 1165 young adults who were low consumers of FV (<3 servings/day) at baseline. INTERVENTION: Online 3-arm program designed to increase FV consumption. MEASUREMENTS: We categorized FV changes into 4 categories: no change or decrease, 1 serving increase, 2 serving increase, and 3 or more serving increase. We then compared the changes in chronic insomnia classification (yes or no), sleep duration, quality, and time to fall asleep (all self-reported) across the FV change categories. Analyses were both overall and stratified by gender, adjusting for potential confounders (depression, physical activity, education, children, and study site). RESULTS: Average age ± SD was 26 ± 2.8 years (71% women). At 3-month follow-up, participants on average increased FV intake by 1.2 ± 1.4 servings. Women who increased FV intake by 3+ servings showed improvements in insomnia symptoms (2-fold higher odds of improvement; 95% CI 1.1 to 3.6), sleep quality (0.2-point higher sleep quality score; 95% CI -0.01, 0.3), and time to fall asleep (4.2 minutes; 95% CI -8, 0) compared to women who did not change or decreased their FV intake. Associations were not as apparent among men. CONCLUSION: Young women with low consumption of FV may experience improvements in insomnia-related sleep difficulties by increasing their consumption of FV.

Influence of a One-Time Web-Based Provider Intervention on Patient-Reported Outcomes After the Well-Child Visit: A Feasibility Study.

PURPOSE: Patient-centered care promotes positive health outcomes in pediatrics. We created a provider-focused intervention and implemented it in a pragmatic clustered randomized controlled trial to improve health-related quality of life (HRQOL) among pediatric patients. METHODS: A one-time (1-1.5-hour) webinar focusing on patient-centered care and motivational interviewing, using obesity screening as an example, was developed. Pediatric providers were recruited and randomized to either intervention (webinar) or control (usual care) arms. All well-child visits to these providers for a period of up to 5 months following webinar completion (or study enrollment for controls) were identified, and these family/patients were invited to complete a survey to assess HRQOL postvisit. Reported outcomes were compared between intervention and control participants using clustered t-tests, chi-squared tests and multiple linear regression models. RESULTS: We recruited 20 providers (10 intervention, 10 control) to the study; 469 parents/guardians and 235 eligible children seeing these providers completed the postvisit survey. Parents/guardians of 8-12-year-old children in the intervention group reported higher school functioning compared to controls (83.5 vs 75.8; P=0.023). There were no other differences in children's HRQOL between intervention and control groups. CONCLUSIONS: A one-time, web-based provider intervention is feasible to implement in pediatrics. Modest evidence, requiring further study, indicates that instructing providers on patient-centered care in the well-child visit may improve aspects of pediatric HRQOL (ie, school functioning) compared to usual care. However, this was a brief intervention, with multiple outcomes tested and no evaluation of pre- and postintervention provider knowledge, thus additional study is needed.

Sleep Duration and Quality in Relation to Fruit and Vegetable Intake of US Young Adults: a Secondary Analysis.

BACKGROUND: Sleep is gaining recognition as a determinant of diet, yet this relationship remains understudied among young adults. We sought to examine how sleep duration and quality were related to fruit and vegetable (FV) intake within a diverse sample of young adults. METHODS: Participants (n = 1444) ages 21-30 (69% women, 15% African American, 35% full or part time in college) consuming < 5 servings/day of FV (eligibility criteria) completed a baseline survey to enroll in a randomized online FV intervention. Sleep questions included duration, perceived sleep quality, time to fall asleep, and insomnia symptoms. Overall and gender-stratified linear regression models compared average daily FV intake and sleep characteristics, adjusting for confounders. RESULTS: One-third (32%) of the participants reported < 7 h of sleep per night, and 36% noted insomnia symptoms ≥ 3 times per week. Women, a BMI > 30, African American race/ethnicity, less education, unemployment, higher depression, and stress were related to suboptimal sleep. Bivariate analyses showed that better sleep was associated with higher FV intake. After accounting for confounders, men with better sleep quality and shorter time to fall asleep had higher intakes of FV (1.12 serving/day difference in highest versus lowest quality [95% CI 0.48, 1.75] and a 0.52 serving/day higher intake difference for shortest versus longest fall asleep time [95% CI 0.90, 0.15], respectively). CONCLUSION: Sleep was highly prevalent in a diverse sample of community-based young adults and may contribute to lower FV intake among men. These associations highlight young adulthood as an important period for promoting healthy sleep habits.

Identifying Effective Motivational Interviewing Communication Sequences Using Automated Pattern Analysis.

Motivational Interviewing (MI) is an evidence-based strategy for communicating with patients about behavior change. Although there is strong empirical evidence linking "MI-consistent" counselor behaviors and patient motivational statements (i.e., "change talk"), the specific counselor communication behaviors effective for eliciting patient change talk vary by treatment context and, thus, are a subject of ongoing research. An integral part of this research is the sequential analysis of pre-coded MI transcripts. In this paper, we evaluate the empirical effectiveness of the Hidden Markov Model, a probabilistic generative model for sequence data, for modeling sequences of behavior codes and closed frequent pattern mining, a method to identify frequently occurring sequential patterns of behavior codes in MI communication sequences to inform MI practice. We conducted experiments with 1,360 communication sequences from 37 transcribed audio recordings of weight loss counseling sessions with African-American adolescents with obesity and their caregivers. Transcripts had been previously annotated with patient-counselor behavior codes using a specialized codebook. Empirical results indicate that Hidden Markov Model and closed frequent pattern mining techniques can identify counselor communication strategies that are effective at eliciting patients' motivational statements to guide clinical practice.

Deep Neural Architectures for Discourse Segmentation in E-Mail Based Behavioral Interventions.

Communication science approaches to develop effective behavior interventions, such as motivational interviewing (MI), are limited by traditional qualitative coding of communication exchanges, a very resource-intensive and time-consuming process. This study focuses on the analysis of e-Coaching sessions, behavior interventions delivered via email and grounded in the principles of MI. A critical step towards automated qualitative coding of e-Coaching sessions is segmentation of emails into fragments that correspond to MI behaviors. This study frames email segmentation task as a classification problem and utilizes word and punctuation mark embeddings in conjunction with part-of-speech features to address it. We evaluated the performance of conditional random fields (CRF) as well as multi-layer perceptron (MLP), bi-directional recurrent neural network (BRNN) and convolutional recurrent neural network (CRNN) for the task of email segmentation. Our results indicate that CRNN outperforms CRF, MLP and BRNN achieving 0.989 weighted macro-averaged F1-measure and 0.825 F1-measure for new segment detection.

5-2-1-0 Lifestyle risk factors predict obesity in Millennials.

The Making Effective Nutritional Choices Generation Y (MENU GenY) study is a web-based intervention trial aimed at improving food choices in those aged 21-30 years. We report baseline levels of the 5-2-1-0 healthy lifestyle patterns to predict a body mass index (BMI) ≥30 vs <30 kg m-2 . Overall, 1674 young adults (69% female) from two large health systems enroled and completed an online survey asking questions about lifestyle habits. A multivariable binary logistic regression model was utilized to predict a BMI ≥30 while controlling for known predictors of obesity. Consuming >3 daily servings of fruits/vegetables (odds ratio, OR = 0.90, 95% confidence interval, CI = 0.81, 0.99), and reporting >2.5 hours/week of vigorous physical activity (OR = 0.93, 95% CI = 0.89-0.96, P < 0.001) was associated with a BMI <30. Conversely, time sitting (OR = 1.07, 95% CI = 1.04, 1.11) and consuming sugar-sweetened beverages (OR = 1.08, 95% CI = 1.00, 1.15) were related to a BMI ≥30. In this cohort of 20-30-year-olds, we observed a consistent relationship between obesity and the 5-2-1-0 healthy lifestyle patterns previously reported among children and adolescents.

Developing Machine Learning Models for Behavioral Coding.

OBJECTIVE: The goal of this research is to develop a machine learning supervised classification model to automatically code clinical encounter transcripts using a behavioral code scheme. METHODS: We first evaluated the efficacy of eight state-of-the-art machine learning classification models to recognize patient-provider communication behaviors operationalized by the motivational interviewing framework. Data were collected during the course of a single weight loss intervention session with 37 African American adolescents and their caregivers. We then tested the transferability of the model to a novel treatment context, 80 patient-provider interactions during routine human immunodeficiency virus (HIV) clinic visits. RESULTS: Of the eight models tested, the support vector machine model demonstrated the best performance, achieving a .680 F1-score (a function of model precision and recall) in adolescent and .639 in caregiver sessions. Adding semantic and contextual features improved accuracy with 75.1% of utterances in adolescent and 73.8% in caregiver sessions correctly coded. With no modification, the model correctly classified 72.0% of patient-provider utterances in HIV clinical encounters with reliability comparable to human coders (k = .639). CONCLUSIONS: The development of a validated approach for automatic behavioral coding offers an efficient alternative to traditional, resource-intensive methods with the potential to dramatically accelerate the pace of outcomes-oriented behavioral research. The knowledge gained from computer-driven behavioral research can inform clinical practice by providing clinicians with empirically supported communication strategies to tailor their conversations with patients. Lastly, automatic behavioral coding is a critical first step toward fully automated eHealth/mHealth (electronic/mobile Health) behavioral interventions.

Effects of a methodological infographic on research participants' knowledge, transparency, and trust.

OBJECTIVE: Given participants' research literacy is essential for clinical trial participation, evidence-based strategies are needed that improve literacy and easily accessed online. We tested whether an infographic letter-that illustrated how dropouts can distort study conclusions-improved participant knowledge about the impact of dropouts relative to a control letter. METHOD: In three distinct online samples purposely recruited to assess reproducibility, young ethnically diverse adults were randomized to read an infographic letter or control letter in a hypothetical scenario. Secondary outcomes included participants' perceived transparency of the research organization, perceived value of retention, and perceived trust of the organization. We purposely included two discriminant items, perceived value for the trial outcome and keeping commitments in general, both hypothesized not to change. RESULTS: Across samples, ∼20% more infographic participants correctly answered how dropouts affected study conclusions than control participants. For example (Experiment 3), nearly 90% of infographic participants correctly answered versus only two thirds of controls (88.7% vs. 66.7%, absolute percentage difference 22.0%, p < .0001). Infographic participants had substantially higher transparency, perceived value for retention, and trust (Cohen's ds = 0.4-1.0, ps < .0001), yet importantly did not value the study outcome or report keeping commitments more than control participants (Cohen's ds = 0.0-0.1, ps > .10). CONCLUSIONS: Promisingly, this transparent, visually powerful methodological infographic improved knowledge and trust. Future trials could embed and experimentally test whether such low-cost online infographics improve not only research literacy, but also trial retention, especially among populations with less initial trust about research. (PsycINFO Database Record

Identifying What Matters to Hysterectomy Patients: Postsurgery Perceptions, Beliefs, and Experiences.

PURPOSE: Hysterectomy is the most common non-obstetrical surgery for women in the United States. Few investigations comparing hysterectomy surgical approaches include patient-centered outcomes. METHODS: The study was performed at Henry Ford Health System in Detroit, Michigan between February 2015 and May 2015. The data were collected through structured focus groups with 24 post-hysterectomy women in order to identify PCOs to employ in a subsequent cohort study of hysterectomy surgical approaches. One pilot focus group and five additional focus groups were held. Qualitative data analysis, using data from coded transcripts of focus groups, was used to identify themes.Eligible women, aged between 18 and 65 years and had an EMR documented Current Procedural Terminology (CPT™) code or an International Statistical Classification of Diseases and Related Health Problems - Ninth Edition (ICD-9) code of hysterectomy between December 2012 and December 2014 (N=1,381, N=307 after exclusions) were selected and recruited. A question guide was developed to investigate women's experiences and feelings about the experience prior and subsequent to their hysterectomy. Analysis utilized the Framework Method. RESULTS: Focus groups with women who previously had a hysterectomy revealed their pre- and post-hysterectomy perceptions. Responses grouped into topics of pre- and post-surgical experiences, and information all women should know. Responses grouped into themes of 1) decision making, 2) the procedure - surgical experience, 3) recovery, 4) advice to past self, and 5) recommendations to other women. CONCLUSION: These findings about perceptions, beliefs, and attitudes of women having undergone hysterectomy could support health care providers deliver patient-centered care. These results informed data collection for a prospective longitudinal cohort study that is now underway. The data suggest a need for increased education and empowerment in the decision making process, while expanding on information given for post-operative expectations and somatic changes that occur post-hysterectomy.

Comparing Reported Dietary Supplement Intakes between Two 24-Hour Recall Methods: The Automated Self-Administered 24-Hour Dietary Assessment Tool and the Interview-Administered Automated Multiple Pass Method.

BACKGROUND: The Automated Self-Administered 24-hour Dietary Assessment Tool (ASA24) includes a highly standardized multipass web-based recall that, like the Automated Multiple Pass Method (AMPM), captures detailed information about dietary intake using multiple probes and reminders to enhance recall of intakes. The primary distinction between ASA24 and AMPM is that the ASA24 user interface guides participants, thus removing the need for interviewers. OBJECTIVE: The objective of this study was to compare dietary supplement use reported on self-administered (ASA24-2011) vs interviewer-administered (AMPM) 24-hour recalls. DESIGN: The Food Reporting Comparison Study was an evaluation study designed to compare self-reported intakes captured using the self-administered ASA24 vs data collected via interviewer-administered AMPM recalls. Between 2010 and 2011, 1081 women and men were enrolled from three integrated health care systems that belong to the National Cancer Institute-funded Cancer Research Network: Security Health Plan Marshfield Clinic, Wisconsin; Henry Ford Health System, Michigan; and Kaiser Permanente Northern California, California. Quota sampling was used to ensure a balance of age, sex, and race/ethnicity. Participants were randomly assigned to four groups, and each group was asked to complete two dietary recalls: group 1, two ASA24s; group 2, two AMPMs; group 3, ASA24 first and AMPM second; and group 4, AMPM first and ASA24 second. Dietary supplements were coded using the 2007-2008 National Health and Nutrition Examination Survey Dietary Supplement Database. Analyses used the two one-sided tests, known as TOST, to assess equivalence of reported supplement use between methods. RESULTS: Complete 24-hour dietary recalls that included both dietary and supplement intake data were available for 1076 participants (507 men and 569 women). The proportions reporting supplement use via ASA24 and AMPM were 46% and 43%, respectively. These proportions were equivalent, with a small effect size of less than 20%. There were two exceptions in subgroup analyses: reported use among those 40 to 59 years of age and reported use by non-Hispanic black subjects were higher for ASA24 than AMPM. CONCLUSIONS: This study provides evidence that there is little difference in reported supplement use by mode of administration (ie, interview-administered vs self-administered recall).

Overweight adolescents and asthma: Revealing motivations and challenges with adolescent-provider communication.

OBJECTIVE: Among teens with asthma, challenges of disease management may be greater in those with a body mass index (BMI) >85th percentile compared to youth within the parameters for normal weight-for-age. This mixed-methods study assessed teens' awareness of the link between weight and asthma management, and perspectives on how medical providers might open a discussion about managing weight. METHOD: Teens aged 13-18, having BMI >85 percentile and chronic asthma, identified using health system databases and a staff email message board, were invited to complete a semi-structured, in-depth phone interview. Interviews were audio taped, transcribed, and qualitatively analyzed, using the Framework Method. Responses were summarized and themes identified. Descriptive summaries were generated for a 16-item survey of weight conversation starters. RESULTS: Of 35 teens interviewed, 24 (69%) were girls, 11 (31%) boys, 20 (63%) African-American. All teens reported having "the weight conversation" with their doctors, and preferred that parents be present. Half knew from their doctor about the link between being overweight and asthma, others knew from personal experience. Nearly all expressed the importance of providers initiating a weight management conversation. Most preferred conversation starters that recognized challenges and included parents' participation in weight management; least liked referred to "carrying around too much weight." CONCLUSIONS: Most teens responded favorably to initiating weight loss if it impacted asthma management, valued their provider addressing weight and family participation in weight management efforts. Adolescents' views enhance program development fostering more effective communication targeting weight improvement within the overall asthma management plan.

Motivations of Young Adults for Improving Dietary Choices: Focus Group Findings Prior to the MENU GenY Dietary Change Trial.

BACKGROUND: Young adulthood is often associated with poor dietary habits that may increase risk of obesity and chronic diseases. As independence grows, little is known about strategies to help balance social, work, and education commitments that may override desires to incorporate healthful food choices. OBJECTIVE: In advance of a randomized trial to test an online intervention targeting young adults, we sought to identify views and experiences with healthy eating, and specifically, eating more fruits and vegetables. METHODS: We conducted 13 focus groups with 68 young adults in metropolitan Detroit (Henry Ford Health System) and rural Pennsylvania (Geisinger Health System). Randomly selected adults aged 21 to 30 years, using health system automated data, were sent recruitment letters. Questions were grounded in social cognitive theory and self-determination theory. Audiotapes were transcribed, content themes identified, coded, verified for reliability, and analyzed qualitatively. RESULTS: Young adults' efforts to eat healthfully included three major themes of (1) motivations to create a healthy lifestyle, teach by example, feel better, and manage weight and future health problems; (2) learning to eat well from childhood, independent living, and peers; and (3) strategies to eat better through planning, tracking, and commitment. DISCUSSION: We uncovered theory-based factors that facilitate healthy dietary behavior change among young adults, including managing their behavior through self-monitoring, goal-setting, small steps, meaningful reinforcements, and social opportunities. CONCLUSIONS: Targeted interventions encouraging reflection on personal values related to meaningful contemporary health benefits are likely to resonate with young adults, as will opportunities to receive and share new information.

Comparison of recruitment and retention among demographic subgroups in a large diverse population study of diet.

OBJECTIVE: We examined the feasibility of conducting a longitudinal study of diet among diverse populations by comparing rates of response throughout recruitment and retention phases by demographic and other characteristics. METHODS: Using quota sampling, participants were recruited from 3 geographically and demographically diverse integrated health systems in the United States. Overall, 12,860 adults, ages 20-70, were invited to participate via mail. Participation first required accessing the study's website and later meeting eligibility criteria via telephone interview. Enrollees were asked to provide two 24-hour dietary recalls, either interviewer-administered or self-administered on the web, over 6 weeks. Stepped monetary incentives were provided. RESULTS: Rates for accessing the study website ranged from 6% to 23% (9% overall) across sites. Site differences may reflect differences in recruitment strategy or target samples. Of those accessing the website, enrollment was high (≥ 87%). Of the 1185 enrollees, 42% were non-Hispanic white, 34% were non-Hispanic black, and 24% were Hispanic. Men and minorities had lower enrollment rates than women and non-Hispanic whites, partially due to less successful telephone contact for eligibility screening. Once enrolled, 90% provided 1 recall and 80% provided both. Women had higher retention rates than men, as did older compared to younger participants. Retention rates were similar across race/ethnicity groups. CONCLUSIONS: While study recruitment remains challenging, once recruited most participants, regardless of race/ethnicity, completed two 24-hour dietary recalls, both interviewer-administered and self-administered on the web. This study demonstrates the feasibility of collecting multiple 24-hour recalls including less expensive automated self-administered recalls among diverse populations.

Teen, Parent, and Clinician Expectations About Obesity and Related Conditions During the Annual Well-Child Visit.

PURPOSE: To examine family (patient and parent/guardian) and clinician preferences for identification and management of obesity and obesity-related conditions during the well-child visit. METHODS: Four focus groups with teen patients (n=16), four focus groups with parents (n=15), and one focus group with providers (n=12) were conducted using a structured moderator guide tailored to each specific population. Eligible patients had a well-child visit during the past 12 months and a diagnosis of overweight, obesity, hyperlipidemia, or elevated blood pressure. Parents who attended their child's well-child visit and had a child meeting these same criteria were eligible. Teen focus groups were divided by gender (male/female) and age (14-15y/16-17y). Focus group transcripts were coded for concepts and themes using qualitative data and thematic analysis. Analysis was performed across groups to determine common themes and domains of intersect. RESULTS: Teens and parents expect weight to be discussed at well-child visits, and prefer discussions to come from a trusted clinician who uses serious, consistent language. Teens did not recognize the health implications from excess weight, and both parents and teens express the need for more information on strategies to change behavior. Providers recognize several challenges and barriers to discussing weight management in the well-child visit. CONCLUSION: A clinician-teen-family relationship built on trust, longevity, teamwork, support, and encouragement can create a positive atmosphere and may improve understanding for weight-related messages for teens and families during a well-child visit.

Providers' Experiences with a Melanoma Web-Based Course: a Discussion on Barriers and Intentions.

Primary care visits provide an opportunity for skin examinations with the potential to reduce melanoma mortality. The INFORMED (INternet curriculum FOR Melanoma Early Detection) Group developed a Web-based curriculum to improve primary care providers' (PCPs') skin cancer detection skills. This study details feedback obtained from participant focus groups, including the feasibility of implementing in other PCP practices. Practicing PCPs at Henry Ford Health System and Kaiser Permanente Northern California completed the curriculum. Feedback sessions were conducted with standardized questions focusing on four domains: (1) overall impressions of the curriculum, (2) recommendations for improvement, (3) current skin examination practices, and (4) suggestions for increasing skin screening by PCPs. Discussions at each site were audio recorded, transcribed verbatim, and de-identified. Providers (N = 54) had a positive impression of the Web-based curriculum, with suggestions to provide offline teaching aids and request assistance. Despite having improved confidence in diagnosing malignant lesions, many providers felt a lack of confidence in performing the screening and time constraints affected their current practices, as did institutional constraints. Providers intended to increase discussion with patients about skin cancer. The accessibility, effectiveness, and popularity of the curriculum indicate potential for implementation in the primary care setting. Participating providers noted that institutional barriers remain which must be addressed for successful dissemination and implementation.