Cluster Randomized Trial of a Church-Based Peer Counselor and Tailored Newsletter Intervention to Promote Colorectal Cancer Screening and Physical Activity Among Older African Americans.

Action Through Churches in Time to Save Lives (ACTS) of Wellness was a cluster randomized controlled trial developed to promote colorectal cancer screening and physical activity (PA) within urban African American churches. Churches were recruited from North Carolina (n = 12) and Michigan (n = 7) and were randomized to intervention (n = 10) or comparison (n = 9). Intervention participants received three mailed tailored newsletters addressing colorectal cancer screening and PA behaviors over approximately 6 months. Individuals who were not up-to-date for screening at baseline could also receive motivational calls from a peer counselor. The main outcomes were up-to-date colorectal cancer screening and Metabolic Equivalency Task (MET)-hours/week of moderate-vigorous PA. Multivariate analyses examined changes in the main outcomes controlling for church cluster, gender, marital status, weight, and baseline values. Baseline screening was high in both intervention (75.9%, n = 374) and comparison groups (73.7%, n = 338). Screening increased at follow-up: +6.4 and +4.7 percentage points for intervention and comparison, respectively (p = .25). Baseline MET-hours/week of PA was 7.8 (95% confidence interval [6.8, 8.7]) for intervention and 8.7 (95% confidence interval [7.6, 9.8]) for the comparison group. There were no significant changes (p = .15) in PA for intervention (-0.30 MET-hours/week) compared with the comparison (-0.05 MET-hours/week). Among intervention participants, PA increased more for those who participated in church exercise programs, and screening improved more for those who spoke with a peer counselor or recalled the newsletters. Overall, the intervention did not improve PA or screening in an urban church population. These findings support previous research indicating that structured PA opportunities are necessary to promote change in PA and churches need more support to initiate effective peer counselor programs.

Physical activity in young adults: a signal detection analysis of Health Information National Trends Survey (HINTS) 2007 data.

Many young adults are insufficiently active to achieve the health benefits of regular physical activity. Using signal detection analysis of data from the 2007 Health Information National Trends Survey, the authors examined distinct subgroups of 18-39 year-old adults who vary in their likelihood of not meeting physical activity recommendations. We randomly split the sample and conducted signal detection analysis on the exploratory half to identify subgroups and interactions among sociodemographic and health communication variables that predicted engaging in less than 150 minutes per week of moderate-intensity physical activity (low physical activity). We compared rates of low physical activity among subgroups with similarly defined subgroups in the validation sample. Overall, 62% of participants did not meet physical activity recommendations. Among 8 subgroups identified, low physical activity rates ranged from 31% to 90%. Predictors of low physical activity were general health, body mass index (BMI), perceived cancer risk, health-related Internet use, and trust in information sources. The least active subgroup (90% low physical activity) included young adults in poor to good health with a BMI of 30.8 or more (obese). The most active subgroup (31% low physical activity) comprised those in very good to excellent health, who used a website to help with diet, weight, or physical activity, and had little to no trust in health information on television. Findings suggest potential intervention communication channels and can inform targeted physical activity interventions for young adults.

Information processing versus social cognitive mediators of weight loss in a podcast-delivered health intervention.

Podcasting is an emerging technology, and previous interventions have shown promising results using theory-based podcast for weight loss among overweight and obese individuals. This study investigated whether constructs of social cognitive theory and information processing theories (IPTs) mediate the effect of a podcast intervention on weight loss among overweight individuals. Data are from Pounds off Digitally, a study testing the efficacy of two weight loss podcast interventions (control podcast and theory-based podcast). Path models were constructed (n = 66). The IPTs, elaboration likelihood model, information control theory, and cognitive load theory mediated the effect of a theory-based podcast on weight loss. The intervention was significantly associated with all IPTs. Information control theory and cognitive load theory were related to elaboration, and elaboration was associated with weight loss. Social cognitive theory constructs did not mediate weight loss. Future podcast interventions grounded in theory may be effective in promoting weight loss.

Process of diffusing cancer survivorship care into oncology practice.

The LIVESTRONG Centers of Excellence were funded to increase the effectiveness of survivorship care in oncology practice. This study describes the ongoing process of adopting and implementing survivorship care using the framework of the diffusion of innovation theory of change. Primary data collection included telephone interviews with 39 members from the eight centers and site visits. Organizational characteristics, overall progress, and challenges for implementation were collected from proposals and annual reports. Creating an awareness of cancer survivorship care was a major accomplishment (relative advantage). Adoption depended on the fit within the cancer center (compatibility), and changed over time based on trial and error (trialability). Implementing survivorship care within the existing culture of oncology and breaking down resistance to change was a lengthy process (complexity). Survivorship care became sustainable as it became reimbursed, and more new patients were seen (observability). Innovators and early adopters were crucial to success. Diffusion of innovation theory can provide a strategy to evaluate adoption and implementation of cancer survivorship programs into clinical practice.

Primary care providers' self-efficacy and outcome expectations for childhood obesity counseling.

BACKGROUND: Primary care providers have a role in the prevention and management of childhood obesity. We explored the relationship of providers' self-efficacy, outcome expectations, and practice level support with childhood obesity counseling frequency. METHODS: Providers (n=123) completed a survey that assessed their self-efficacy, outcome expectations, and reported obesity counseling frequency. A practice level assessment tool was used to characterize the practices. We analyzed data using frequencies and proportional odds modeling. RESULTS: Providers were confident or very confident (78.5-93.5%) in their ability to counsel about healthy eating, physical activity, and weight and agreed or strongly agreed (64.2-86.2%) that their counseling would result in actual changes. Providers with higher outcome expectations were more likely [odds ratio (OR)=3.4] to report providing obesity counseling. Female providers were more likely to report counseling about obesity (OR=2.3) than males. Providers in practices with resources for healthy eating and physical activity reported higher levels of self-efficacy and counseling frequency. CONCLUSIONS: In our study, providers were confident in their ability to provide obesity counseling and expected changes from their efforts, suggesting that future studies should build on the high level of outcome expectations as well as self-efficacy. The gender difference found regarding obesity counseling may need further exploration.

Delivering health information via podcast or web: media effects on psychosocial and physiological responses.

This study explored differences in psychosocial and physiological variables in response to being presented with information on weight loss through either reading text on a website or listening to the same information via podcast. Participants were randomized to receive a weight loss website (n = 20) or podcast (n = 20). Participants had skin conductance levels measured and completed questionnaire items assessing demographic characteristics, user control, novelty, and knowledge. Participants in the podcast group exhibited greater levels of physiological arousal and reported the intervention to be more novel than those in the Web group; however, the Web group reported greater user control. There was no difference in knowledge between the groups. This study presents the first step in examining the role that novelty and user control may play in two different weight-loss electronic media, as well as differences in knowledge acquisition. Future research should explore adding additional media features, such as video content, to the podcasts and websites in order to optimize fully the different mediums and to examine whether user control and novelty are potential mediators of weight loss outcomes.

Colorectal cancer screening and physical activity promotion among obese women: an online evaluation of targeted messages.

Obese women are at higher risk for several cancers, but are less likely than normal weight women to engage in cancer prevention behaviors such as screening and physical activity. Targeted health messages may help increase healthy behaviors among vulnerable groups such as obese women. Using findings from focus groups with obese women, the authors created targeted messages to promote colorectal cancer screening and physical activity among obese women. The messages addressed psychosocial constructs, such as benefits and barriers to colorectal cancer screening and exercise, which were relevant to the target population. Messages were tested online with women age 50 years and older (N = 181). Participants were stratified by weight (obese vs. nonobese) and randomized to review either 10 targeted (intervention) or 10 generic (control) messages. Study outcomes included elaboration about the messages, message relevance and trustworthiness, and behavioral intentions. The authors used moderation and subgroup analyses to determine whether the intervention messages were better received by certain women. They found no differences in elaboration, behavioral intentions, relevance, or trustworthiness between intervention and control for either weight group. However, exercise intentions increased more (p = .06) among inactive obese women who received intervention messages (+2.9) compared with those who were in the control group (+1.2). Intervention messages also produced more elaboration among women who viewed their weight as a barrier to screening or exercise. Tailoring intervention messages for obese women on the basis of behavior and barriers may improve outcomes more than giving the same messages to all obese women.

Evaluating the dissemination of Body & Soul, an evidence-based fruit and vegetable intake intervention: challenges for dissemination and implementation research.

OBJECTIVE: To evaluate whether the evidence-based Body & Soul program, when disseminated and implemented without researcher or agency involvement and support, would achieve results similar to those of earlier efficacy and effectiveness trials. DESIGN: Prospective group randomized trial. SETTING: Churches with predominantly African American membership. PARTICIPANTS: A total of 1,033 members from the 15 churches completed baseline surveys. Of these participants, 562 (54.4%) completed the follow-up survey 6 months later. INTERVENTION: Church-based nutrition program for African Americans that included pastoral involvement, educational activities, church environmental changes, and peer counseling. MAIN OUTCOME MEASURE: Daily fruit and vegetable (FV) intake was assessed at pre- and posttest. ANALYSIS: Mixed-effects linear models. RESULTS: At posttest, there was no statistically significant difference in daily servings of FVs between the early intervention group participants compared to control group participants (4.7 vs 4.4, P = .38). Process evaluation suggested that added resources such as technical assistance could improve program implementation. CONCLUSIONS AND IMPLICATIONS: The disseminated program may not produce improvements in FV intake equal to those in the earlier efficacy and effectiveness trials, primarily because of a lack of program implementation. Program dissemination may not achieve public health impact unless support systems are strengthened for adequate implementation at the church level.

Implementing the MOVE! weight-management program in the Veterans Health Administration, 2007-2010: a qualitative study.

INTRODUCTION: One-third of US veterans receiving care at Veterans Health Administration (VHA) medical facilities are obese and, therefore, at higher risk for developing multiple chronic diseases. To address this problem, the VHA designed and nationally disseminated an evidence-based weight-management program (MOVE!). The objective of this study was to examine the organizational factors that aided or inhibited the implementation of MOVE! in 10 VHA medical facilities. METHODS: Using a multiple, holistic case study design, we conducted 68 interviews with medical center program coordinators, physicians formally appointed as program champions, managers directly responsible for overseeing the program, clinicians from the program's multidisciplinary team, and primary care physicians identified by program coordinators as local opinion leaders. Qualitative data analysis involved coding, memorandum writing, and construction of data displays. RESULTS: Organizational readiness for change and having an innovation champion were most consistently the 2 factors associated with MOVE! implementation. Other organizational factors, such as management support and resource availability, were barriers to implementation or exerted mixed effects on implementation. Barriers did not prevent facilities from implementing MOVE! However, they were obstacles that had to be overcome, worked around, or accepted as limits on the program's scope or scale. CONCLUSION: Policy-directed implementation of clinical weight-management programs in health care facilities is challenging, especially when no new resources are available. Instituting powerful, mutually reinforcing organizational policies and practices may be necessary for consistent, high-quality implementation.

Cancer screening patterns by weight group and gender for urban African American church members.

Obese white women have lower rates of cancer screening compared to non-obese women. This study will determine if a relationship exists between weight and adherence to cancer screening guidelines among African Americans. We used multivariate logistic regression to examine the relationship between being up-to-date with cancer screening (colorectal, breast, cervical, and prostate) and weight group (normal, overweight, obese I, obese II+) using data from older (age 50+) members (N = 955) of 20 African American churches in Michigan and North Carolina. CRC testing rates were examined using multiple definitions to account for differences in screening rates vs. polyp surveillance rates. After adjusting for confounders, we found relationships between weight group and up-to-date CRC (P = 0.04) and PSA (P = 0.004) testing for men and mammography (P = 0.03) for women. Compared to normal-weight men, obese I men were more likely to be up-to-date with CRC (OR 2.35, 95%CI 1.02-5.40) and PSA (OR 4.24 95%CI 1.77-10.17) testing. CRC screening rates were lower when individuals with polyps were excluded from the analysis; however, patterns by weight remained the same. Contrary to previous research, we did not find lower rates of cancer screening among obese African Americans. Instead, we found that normal-weight African American men had lower screening rates than any other group. As we did not consistently find lower screening rates among obese African Americans, targeting this group for increased screening promotion may not be the most effective way to reduce weight-related cancer disparities.

An examination of sociodemographic, health, psychological factors, and fruit and vegetable consumption among overweight and obese U.S. veterans.

A diet high in fruits and vegetables (F&Vs) is associated with decreased risk for cardiovascular disease, diabetes, and cancer. This study investigated the relationship between sociodemographic, health, and psychosocial factors and F&V consumption among overweight and obese U.S. veterans. Participants were recruited from two Veterans Affairs medical center sites in 2005. Two hundred eighty-nine participants completed a self-administered survey. Bivariate and multivariate linear regression models were built to examine the association between sociodemographic, health, and psychosocial variables and F&V consumption. Older age (B = 0.01; p < 0.001) and being Black (B = -0.18; p < 0.05) were related to increased F&V consumption. Reported tobacco use was inversely associated with F&V consumption (B = -0.30; p < 0.01). Greater self-efficacy (B = 0.07; p < 0.05), fewer perceived barriers (B = -0.14; p < 0.01), and correct knowledge of recommended daily F&V intake (B = 0.12; p <0.05) were related to eating more F&Vs. U.S. veterans disproportionately experience overweight and obese conditions. Age, race, tobacco use, and psychosocial factors should be considered carefully when developing dietary interventionsamong overweight ana obese U.S. veterans.

Adult cancer survivorship care: experiences from the LIVESTRONG centers of excellence network.

BACKGROUND: The objectives of this study were to characterize survivorship models of care across eight LIVESTRONG Survivorship Center of Excellence (COE) Network sites and to identify barriers and facilitators influencing survivorship care. METHODS: Using the framework of the Chronic Care Model (CCM), quantitative and qualitative methods of inquiry were conducted with the COEs. Methods included document reviews, key informant telephone interviews with 39 participants, online Assessment of Chronic Illness Care (ACIC) surveys with 40 participants, and three site visits. RESULTS: Several overarching themes emerged in qualitative interviews and were substantiated by quantitative methods. Health system factors supporting survivorship care include organization and leadership commitment and program champions at various levels of the health care team. System barriers include reimbursement issues, lack of space, and the need for leadership commitment to support changes in clinical practices as well as having program "champions" among clinical staff. Multiple models of care include separate survivorship clinics and integrated models as well as consultative models. COEs' scores on the ACIC survey showed overall "reasonable support" for survivorship care; however, the clinical information system domain was least developed. Although the ACIC findings indicated "reasonable support" for self-management, the qualitative analysis revealed that self-management support was largely limited to health promotion provided in clinic-based education and counseling sessions, with few COEs providing patients with self-management tools and interventions. CONCLUSIONS: The CCM framework captured experiences and challenges of these COEs and provided insight into the current state of survivorship care in the context of National Cancer Institute-designated comprehensive cancer centers. Findings showed that cancer patients and providers could benefit from clinical information systems that would better identify candidates for survivorship care and provide timely information. In addition, a crucial area for development is self-management support outside of clinical care. IMPLICATIONS FOR CANCER SURVIVORS: Cancer survivors may benefit from learning about the experience and challenges faced by the eight LIVESTRONG Centers of Excellence in developing programs and models for cancer survivorship care, and these findings may inform patient and caregiver efforts to seek, evaluate, and advocate for quality survivorship programs designed to meet their needs.

Information processes mediate the effect of a health communication intervention on fruit and vegetable consumption.

Health communication interventions have been effective in promoting fruit and vegetable consumption (FVC). To explore mechanisms underlying health communication effectiveness, the authors investigated whether information processes mediated the relationship between health communication and FVC, using data from NC STRIDES. NC STRIDES tested the efficacy of two health communication strategies to promote FVC among a diverse population-based sample of older adults. Participants were randomized to 1 of 4 groups: control, tailored print communication (TPC), telephone motivational interviewing (TMI), or combined (TPC + TMI). To analyze data from 469 participants, the authors constructed multi-sample structural equation models. Information processes mediated the effect of TMI and TPC + TMI on FVC. TMI had an indirect effect on FVC through relevance of the communications. TPC + TMI influenced FVC through perceived relevance of the communications, trust in the communications, and dose recall via two paths. In the first path, relevance was associated with trust. Trust was associated with recall, and greater recall predicted FVC. In the second path, relevance was associated with dose recall, and more recall predicted FVC. Thus, the authors found that key information processes mediated the relationship between a health communication intervention and FVC. Further research should investigate ways to enhance relevance, trust, and recall during the delivery of interventions.

Obesity predicts differential response to cancer prevention interventions among African Americans.

Wellness for African Americans Through Churches was a randomized trial that tested the effectiveness of tailored print and video (TPV) and/or lay health advisors (LHA) at increasing recreational physical activity (RPA), fruit and vegetable (F&V) consumption, and colorectal cancer (CRC) screening in African American churches. Baseline data revealed lower screening and RPA rates among obese individuals but no weight-related differences in F&V consumption. This analysis examined if intervention effectiveness was also moderated by participant weight group. Regression analyses tested for interactions between intervention and weight group for screening and RPA. Weight group was found to be a moderator of intervention effectiveness (p = .02); normal and overweight individuals receiving the LHA intervention increased RPA more, whereas obese individuals responded better to TPV. For CRC screening, the interaction term was not significant; weight alone was related to screening at follow-up (p = .049), with obese individuals reporting less screening. These results suggest that weight tailoring may improve the effectiveness of behavior change interventions.

Results of a randomized trial testing messages tailored to participant-selected topics among female college students: physical activity outcomes.

BACKGROUND: A better understanding of identifying tailoring variables would improve message design. Tailoring to a behavior that a participant selects as one they would like to work on may increase message relevance, and thus effectiveness. This trial compared 3 groups: message tailored to physical activity as a participant-selected topic (choice), message tailored to physical activity as an expert-determined topic (expert), or nontailored message (comparison). METHODS: 408 female college students received web-delivered computer-tailored messages on physical activity. Outcomes were immediate and 1-month follow-up changes in psychosocial, goal-related, and behavioral variables related to physical activity. RESULTS: Participants were predominately non-Hispanic White (73.8%). Change in self-efficacy and goal commitment at immediate follow-up and vigorous physical activity at 1-month follow-up was greater in the expert versus comparison group. Change in goal commitment at immediate follow-up was lower in the choice versus expert group. In the expert group, those choosing physical activity as their selected topic perceived the goal to be easier at immediate follow-up compared with those receiving unmatched messages. CONCLUSIONS: Findings supported tailoring to an expert-determined topic. However, based on the beneficial change in perceived goal difficulty when topics matched, future research should encourage synchrony between participant-selected topics and expert recommendations.

Pilot weight control intervention among US veterans to promote diets high in fruits and vegetables.

BACKGROUND: Obesity is a significant problem among US veterans. Diets high in fruits and vegetables (FV) can lower obesity risk. Health communication interventions are promising strategies for promoting healthy eating. We evaluated whether an enhanced intervention with tailored newsletters and motivational interviewing calls would be more effective than the Veterans Affairs (VA) weight management program, MOVE!, at increasing FV intake among overweight/obese veterans. METHODS: Using a quasi-experimental design, 195 veterans at two clinics participated at baseline and 6-month follow-up from 2005 to 2006. Measures included daily FV intake and information processing of the intervention. The control group (MOVE!) received educational information, group sessions, and standard phone calls about weight. The intervention included MOVE! components plus tailored newsletters and motivational interviewing calls. RESULTS: The intervention group reported a statistically significant increase in FV servings compared to control (1.7 vs. 1.2; p ≤ 0.05). Veterans who read more of the tailored newsletters (ß=0.15, p=0.01) and perceived the messages as important (ß=0.12, p<0.01) and applicable to their lives (ß=0.12, p<0.01) ate more FV than those who did not. However, receiving MI calls and information processing regarding the calls were not associated with FV intake. CONCLUSION: A tailored intervention can impact short term FV intake for obesity prevention.

Mediators of fruit and vegetable consumption among colorectal cancer survivors.

INTRODUCTION: Due to early detection and treatment, survival from colorectal cancer (CRC) diagnosis has been steadily increasing. A CRC diagnosis could be considered a "teachable moment," a time when interventionists might successfully promote dietary changes. CRC interventions with tailored print communication (TPC) and telephone motivational interviewing (TMI) have been shown to be effective in promoting fruit and vegetable consumption (FVC) among CRC survivors. However, little is known about how these interventions work to exert their effect. This study investigated whether information processes mediate the relationship between a CRC intervention and FVC among CRC survivors. METHODS: This research used data from NC STRIDES, a study that tested the efficacy of two CRC intervention strategies to promote FVC among CRC survivors. Participants were randomized to control, TPC, TMI, or combined (TPC+TMI). Structural equation models were constructed to analyze data from 266 CRC survivors using two different measures of FVC, a 35-item and a 2-item measure. RESULTS: Two information processes, relevance of communication and trust in the communication, mediated the effect of TPC+TMI on FVC for both 35-item and 2-item measures. TPC+TMI was significantly associated with relevance of communication, and perceiving greater relevance was significantly related to trust in the communication. Trust was significantly related to FVC. DISCUSSION: Information processes, including relevance and trust in the communication, serve as mediators of the relationship between the CRC intervention and FVC. IMPLICATIONS FOR CANCER SURVIVORS: Future intervention research should investigate ways to enhance relevance of communication and trust in interventions with CRC survivors.

Evaluating the implementation of peer counseling in a church-based dietary intervention for African Americans.

OBJECTIVE: Body & Soul, an evidence-based nutrition program for African Americans churches, is currently being disseminated nationally and free of charge by the National Cancer Institute. For dissemination feasibility, the peer counseling training is done via DVD rather than by live trainers. We describe implementation and process evaluation of the peer counseling component under real world conditions. METHODS: The study sample included 11 churches (6 early intervention, 5 delayed intervention) in 6 states. Data sources included training observations, post-training debriefing sessions, coordinator interviews, and church participant surveys. Survey data analysis examined associations between exposure to peer counseling and change in dietary intake. Qualitative data were analyzed using the constant comparative method. RESULTS: Eight of 11 churches initiated the peer counseling program. Recall of talking with a peer counselor was associated with significantly (p<.02) greater fruit and vegetable intake. Data indicate sub-optimal program execution after peer counselor training. CONCLUSION: Inconsistent implementation of the peer counseling intervention is likely to dilute program effectiveness in changing nutrition behaviors. PRACTICE IMPLICATIONS: Disseminating evidence-based programs may require added resources, training, quality control, and technical assistance for improving program uptake. Similar to earlier research phases, systematic efforts at the dissemination phase are needed for program success.

Race moderates the relationship between obesity and colorectal cancer screening in women.

OBJECTIVE: To determine if the relationship between obesity and usage of colorectal cancer (CRC) screening in women varies when stratifying by race. METHODS: Using nationally representative data from the 2005 National Health Interview Survey, we examined the relationship between obesity and CRC screening for white and African-American women aged 50 and older. Screening usage variables indicated if a woman was up-to-date for any CRC screening test, colonoscopy, or FOBT. We used multivariable logistic regression models that included interaction terms to determine if race moderates the obesity-screening relationship. We also calculated adjusted up-to-date colonoscopy rates using direct standardization to model covariates. RESULTS: The relationship between obesity and screening differed by race for any CRC screening test (P = 0.04 for interaction) and for colonoscopy (P = 0.01 for interaction), but not for FOBT. Obese white women had a lower adjusted colonoscopy rate (30.2%, 95% CI 25.9-34.8) than non-obese white women (39.1%, 95% CI 36.1-42.2). Obese African-American women, on the other hand, had a higher adjusted colonoscopy rate (41.2%, 95% CI 31.6-51.4) than their non-obese counterparts (35.6%, 95% CI 28.3-43.6). Overall, adjusted colonoscopy rates were lowest among obese white women. CONCLUSIONS: Obesity is associated with lower CRC screening rates in white, but not African-American women.