A cluster randomized controlled trial of a brief positive healthy eating intervention.

Excessive sugar intake poses a significant risk factor for non-communicable diseases. A positive healthy eating (PHE) intervention was developed to promote low-sugar dietary practices in families. The PHE intervention capitalized on positive psychological constructs to overcome barriers to health behavior change by helping families associate feelings of joy, gratitude, and savoring with healthy eating. In a cluster randomized controlled trial, 1983 participants from 1467 families were recruited in Hong Kong. PHE included a core and booster session. Data were collected at pre-intervention, post-intervention, and at 1-month and 3-month follow-up. Compared to the control, PHE showed greater increase in intention to change at post-intervention, engagement in low-sugar dietary practices individually and with family members at 3-month follow-up, and greater reduction in sugar-sweetened beverage intake at 1-month and 3-month follow-up. Intentions to change mediated PHE's effects on low-sugar dietary practices. Focus group interviews revealed the behavior-change process and family quality of life.

Implementation and evaluation of a model-based risk management process and service enhancement for home-based community care services amidst COVID-19 pandemic in Hong Kong: A mixed-method approach.

Background: The COVID-19 pandemic has greatly challenged all public social services, particularly home-based community care services (HBCCS). Aberdeen Kai-fong Association (AKA) is a non-government organization (NGO) in Hong Kong that systematically manages the challenges to HBCCS. This paper presents a practical example of the implementation and evaluation of the risk management process for HBCCS. Methods: Mixed-method design was used to evaluate the implementation of the risk management process in encountering the challenges from existing and potential problems to maintain and enhance HBCCS in four major areas amidst the pandemic. A cross-sectional questionnaire survey and three qualitative focus group interviews were conducted by AKA from 30 December 2021 to 12 March 2022 to collect staff feedback on the institutional risk management process in four areas. Results: 109 HBCCS staff members (69% aged 40 years or above; 80% female) completed the questionnaire survey. For resource arrangement and staff training, over 90% of the participants agreed (including strongly agreed) that they had sufficient and reliable personal protective equipment and clear infection control guideline and effective training. Over 80% agreed they had safe working space and effective manpower allocation. However, only 75% agreed they had received emotional support from the organization. Over 90% agreed that the basic services were maintained for service continuation and enhancement, the service users and their families trusted the organization, and the provided services were adjusted according to users' needs. 88% agreed that the organization had obtained support from the neighborhood. For communication among stakeholders, over 80% agreed they had open discussions with the senior management team, and the senior management team was willing to listen. Twenty-six staff members joined the three focus group interviews. The qualitative findings corroborated the quantitative results. Staff appreciated the organisation's work to enhance staff safety and continue advancing services during this difficult period. Regular in-service training, updated information and guidelines to staff, and proactive phone calls to service users, especially the elderly, were suggested to enhance the quality of services. Conclusions: The paper could help NGOs and others encountering management challenges in community social services in diverse settings amidst the pandemic and beyond.

Mental Health, Support System, and Perceived Usefulness of Support in University Students in Hong Kong Amidst COVID-19 Pandemic: A Mixed-Method Survey.

BACKGROUND: This study explored the association of students' mental health with their support system, identified the preferred ways and sources of support, investigated the perceived usefulness of available university support, and recommended actionable strategies to enhance students' mental health. METHOD: An online questionnaire survey and semi-structured focus group interviews were conducted in 2021. RESULTS: Among 1121 university students, 39.4% reported anxiety symptoms, which were less common in Chinese students and those pursuing medical and health programmes. Overall, 32.6% reported depression symptoms, which were more common in undergraduates. Both anxiety and depression symptoms were less common in students with higher resilience and support system and more common in students with family distress. Students with higher resilience had a better support system and less family distress. Perceived support from universities was lower than from peers and families. Peer support and phone contacts were the most preferred sources and ways of support. The most useful available university support was updated university guidelines, and the least useful was the emotional hotline service from universities The qualitative findings corroborated the quantitative results. CONCLUSION: We suggested that a holistic care approach and more proactive student-oriented university support would help students face adversity and enhance mental health.

COVID-19 pandemic fatigue and its sociodemographic and psycho-behavioral correlates: a population-based cross-sectional study in Hong Kong.

Pandemic fatigue is a growing public health concern of the lingering COVID-19 pandemic. Despite its widespread mass media coverage, systematic empirical investigations are scarce. Under the Hong Kong Jockey Club SMART Family-Link Project, we conducted online and telephone surveys amid the pandemic in February to March 2021 to assess self-reported pandemic fatigue (range 0-10) in Hong Kong adults (N = 4726) and its associations with sociodemographic and psycho-behavioral (high vs low to moderate) variables. Data were weighted by sex, age, and education of the general population. Binary logistic regression models yielded adjusted odds ratios (aORs) for high pandemic fatigue (score ≥ 7) for sociodemographic and psycho-behavioral variables. 43.7% reported high pandemic fatigue. It was less common in older people (55-64 years: aOR 0.56, 95% CI 0.39-0.82; 65 + years: 0.33, 0.21-0.52) versus age group 18-24 years, but more common in those with tertiary education (1.36, 1.15-1.62) versus secondary or below. High pandemic fatigue was positively associated with depressive symptoms (aOR 1.83, 95% CI 1.55-2.17), anxiety symptoms (1.87, 1.58-2.20), loneliness (1.75, 1.32-2.31), personal fear of COVID-19 (2.61, 2.12-3.23), family fear of COVID-19 (2.03, 1.67-2.47), and current alcohol use (1.16, 1.00-1.33), but negatively associated with self-rated health (0.79, 0.68-0.92), personal happiness (0.63, 0.55-0.72), personal adversity coping capability (0.71, 0.63-0.81), family adversity coping capability (0.79, 0.69-0.90), family well-being (0.84, 0.73-0.97), family communication quality (0.86, 0.75-0.98), and frequent home exercise (0.82, 0.69-0.96; versus less frequent). We first used a single-item tool to measure COVID-19 pandemic fatigue, showing that it was common and associated with worse mental health, lower levels of personal and family well-being and alcohol use.

Feasibility and Potential Effectiveness of a Smartphone Zero-Time Exercise Intervention for Promoting Physical Activity and Fitness in Patients With Coronary Heart Disease: A Pilot Randomized Controlled Trial.

Background: Zero-time Exercise (ZTEx), a simple strength- and stamina-enhancing physical activity (PA) requiring no extra equipment, can potentially increase PA and fitness. This pilot trial examined the feasibility and potential effectiveness of a smartphone ZTEx intervention to promote PA and fitness in patients with coronary heart disease (CHD). Methods: A parallel-group assessor-blinded pilot randomized controlled trial was conducted on Chinese patients with stable coronary heart disease (CHD) in three cardiology clinics. The experimental group received a 15-min brief individual face-to-face session and a 12-week ZTEx instant messaging with 28 picture e-messages and a smartphone ZTEx application (ZTExApp). The control group received the same duration of individual session and number and format of e-messages, but the content was healthy eating and breathing exercise. The feasibility was assessed based on: attrition rate, usage, response rate and perception of the intervention. The outcome evaluation included primary outcome (PA), fitness, exercise self-efficacy and intention, perceived happiness and health, and quality of life. A linear mixed model was used with intention-to-treat analysis adjusting for sex, age and baseline values. A semi-structured interview was conducted to collect feedback from the experiment group. Results: One hundred thirty-nine patients (mean age 59.8 ± 6.6; 71.2% male) were randomized to the experimental group (n = 70) or control group (n = 69), and 80% (56/70) and 82% (57/69) of patients completed the 12-week follow-up assessment, respectively. The attrition rate was 18.7%. The experimental group reported that ZTEx was feasible to integrate PA into their daily life and appreciated the picture e-messages, and 95% of them sent feedback to us, but only 19.6% (13/70) of the participants entered their PA information into the e-diary of the ZTExApp. The experimental group had a significantly greater increase in time spent walking [mean difference (95% CI): 155.3 (10.1, 300.4), P = 0.04, Cohen's d = 0.34] than the control group. Conclusions: This pilot study showed using a brief ZTEx face-to-face session with picture e-messages empowered patients with CHD to integrate PA into daily life. Future definitive trials with a longer follow-up and a more user-friendly ZTExApp interface are necessary to determine the effectiveness of the smartphone ZTEx intervention in enhancing PA and related outcomes. Trial Registration: The research protocol was registered at the Hong Kong University Clinical Trials Registry (HKUCTR) on 22 Jul 2016 (Study identifier: HKUCTR-2165) and was also retrospectively registered at the National Institutes of Health (identifier number: NCT03464331) on 14 March 2018.

Factor Structure and Psychometric Properties of the Family Communication Scale in the Chinese Population.

Purpose: To evaluate the factor structure and psychometric properties of the 10-item Family Communication Scale (FCS) in the Chinese population. Methods: Study 1 was a population-based survey [N = 687, 61.1% female; mean age (SD) 56.6 (19.1)]. Study 2 was a community-based intervention (N = 1983, 76.7% female; 57.8% aged 20-59 years). We conducted exploratory factor analysis (EFA) in Study 1 and replicated the model by confirmatory factor analysis (CFA) in Study 2. Psychometric properties were evaluated, including internal consistency, test-retest reliability, convergent and discriminant validity, and known-group validity. We identified how the FCS scores differed by sociodemographic characteristics and communication methods including face to face and Information and Communication Technologies (ICTs) in Study 1. Results: The EFA and CFA supported a one-factor structure. The Chinese FCS showed a good internal consistency (Cronbach's alpha = 0.91; McDonald's Omega = 0.91) and was stable over 1-month (intraclass correlation coefficient = 0.69, P < 0.001). Convergent validity was supported by positive correlations of FCS with the Subjective Happiness Scale, Family Adaption, Partnership, Growth, Affection, Resolve (APGAR) Scale, family health, harmony, and happiness, and perceived family communication sufficiency and quality (All P < 0.001). Discriminant validity was supported by the stronger correlation of FCS with Short Form-12 Health Survey Version 2 Mental Component than that with Physical Component (P < 0.001). Higher household income, frequent face-to-face communication, and frequent use of phone calls, instant messaging, and social networking sites were associated with higher FCS scores. Conclusion: The one-factor structure of the Chinese FCS can be a reliable and valid measurement of positive family communication, in the context of ICT integration into family communication. Clinical Trial Registration: [www.ClinicalTrials.gov], identifier [NCT02563613].

A Randomized Controlled Trial of a Positive Family Holistic Health Intervention for Probationers in Hong Kong: A Mixed-Method Study.

Introduction: Probationers, offenders with less serious and non-violent offences, and under statutory supervision, have low levels of self-esteem and physical health, and high level of family conflict, and poorer quality of family relationships. This study examined the effectiveness of the existing probation service and the additional use of a positive family holistic health intervention to enhance physical, psychological, and family well-being in probationers and relationships with probation officers. Methods: Probationers under the care of the Hong Kong Social Welfare Department were randomized into a care-as-usual control group (CAU), a brief intervention group (BI) receiving two 1-h individual sessions [of a brief theory-based positive family holistic health intervention integrating Zero-time Exercise (simple and easy-to-do lifestyle-integrated physical activity) and positive psychology themes of "Praise and Gratitude" in the existing probation service], or a combined intervention group (CI) receiving BI and a 1-day group activity with family members. The outcomes were physical activity, fitness performance, self-esteem, happiness, anxiety and depression symptoms, life satisfaction, quality of life, family communication and well-being, and relationships with probation officers. Self-administered questionnaires and simple fitness tests were used at baseline, 1-month and 3-month follow-up. Linear mixed model analysis was used to compare difference in the changes of outcome variables among groups, adjusted of sex, age, and baseline values. Focus group interviews were conducted. Thematic content analysis was used. Results: 318 probationers (51% male) were randomized into CAU (n = 105), BI (n = 108), or CI (n = 105) group. CAU showed enhanced physical activity, fitness performance and psychological health, and family communication with small effect sizes (Cohen's d: 0.19-0.41). BI and CI showed further improved physical activity, family communication and family well-being (Cohen's d: 0.37-0.70). Additionally, CI reported greater improvements in the relationships with probation officers than CAU with a small effect size (Cohen's d: 0.43). CI also reported greater increases in physical activity and family communication than BI with small to moderate effect sizes (Cohen's d: 0.38-0.58). Qualitative feedbacks corroborated the quantitative findings. Conclusion: Our trial provided the first evidence of the effectiveness of probation service and the additional use of an innovative, relatively low-cost, theory-based brief positive family holistic health intervention. This intervention may offer a new model for enhancing probation service. Trial Registration: The research protocol was registered at the National Institutes of Health (identifier: NCT02770898).

A Community-Based Lifestyle-Integrated Physical Activity Intervention to Enhance Physical Activity, Positive Family Communication, and Perceived Health in Deprived Families: A Cluster Randomized Controlled Trial.

Background: Zero-time exercise (ZTEx) is an approach integrating simple strength- and stamina-enhancing physical activity into daily life. The study evaluated the effectiveness of a community-based lifestyle-integrated physical activity intervention using ZTEx to enhance participants' physical activity, family communication, perceived health and happiness, and family harmony. Methods: A parallel group, cluster randomized controlled trial was conducted in a sample of 673 participants from eight Integrated Family Service Centers in Hong Kong. The experimental group (n = 316) received a physical activity intervention. The control group (n = 357) received information on healthy eating. Both groups received three face-to-face intervention sessions (totalling 6 h and 30 min) and 16 text messages. The primary outcome was the change in days spent engaged in ZTEx. Secondary outcomes included changes in sitting time, days engaged in moderate or vigorous physical activities, family communication (encouraging and engaging family members in ZTEx), dietary habits, perceived health and happiness, and family harmony. Self-administered questionnaires were used at baseline and at 3, 6, and 12 months. Mixed effects models with intention-to-treat analysis was used. Results: Compared with the control group at 3 months, the experimental group showed significantly greater increases of 1.3 days spent doing ZTEx (Cohen's d: 0.60), 0.3 days spent doing moderate physical activity (Cohen's d: 0.08), 0.3 days encouraging family members to do ZTEx (Cohen's d: 0.16), and 0.7 days doing ZTEx with family members (Cohen's d: 0.39) during the 7 days prior. At 3 months, the experimental group also showed a significantly greater improvement in perceived health, by a score of 0.2 (Cohen's d: 0.14). The effect sizes ranged from small to medium, with similar intervention effects at the 6-month and 1-year assessments. Compared with the experimental group, the control group showed a significantly greater reduction of 0.4 days on which sweetened beverages were consumed (95% CI: 0.01, 0.9, p < 0.05, Cohen's d: 0.28). The qualitative results supported the quantitative findings. Conclusions: Our findings show that a community-based lifestyle-integrated physical activity (PA) intervention can enhance physical activity, family communication, and perceived health in deprived families in Hong Kong. Trial registration: The research protocol was retrospectively registered at the National Institutes of Health (identifier number: NCT02601534) on November 10, 2015.

Process Evaluation and Experience Sharing on Utilizing Information Communication Technologies and Digital Games in a Large Community Family Health Event: Hong Kong Jockey Club SMART Family-Link Project.

Background: Information communication technologies (ICT) are increasingly used in health promotion, but integration is challenging and involves complex processes. Large community health promotion events are often held but the experiences and processes have rarely been evaluated and published. No reports have described and systematically evaluated an ICT-supported health promotion event using digital games. Objective: We evaluated the development and implementation of a large community family health promotion event with ICT integration to promote family happiness with collaboration between academia (The University of Hong Kong) and the social (family) service sector, and collected feedback from participants and social service workers. Methods: We (i) conducted a systematic process evaluation, (ii) administered an on-site questionnaire survey on participant satisfaction and feedback, and (iii) collected post-event qualitative feedback from social workers on using new technologies, digital game design and overall experiences. Results: Fourteen digital games were designed and run in booths at the event by 12 non-governmental social service organizations and academia. Four gaming technologies were utilized: chroma key (green screen), somatosensory (kinect and leap motion techniques), augmented reality and virtual reality. 1,365 participants joined the event, in which 1,257 from 454 families were recruited and pre-registered through 12 NGOs. About 39.3% were male and more than half (53.3%) were aged 18 years and above. About 3,487 game booth headcounts were recorded. Games using virtual reality, kinect motion and green screen technologies were most liked. The average game satisfaction score was high (4.5 out of 5). Social service workers reported positive experiences with using new technologies in health promotion, and interests in future collaborations involving more ICT. Conclusions: Our systematic evaluation showed successful integration of ICT components in the health promotion event. This event, most likely the first of its kind, served as a capacity building and knowledge transfer platform for interdisciplinary co-sharing and co-learning of new technologies. It provided a solid foundation for further academic and social service partnerships and should be a useful model for similar community events and their evaluation. Further development and integration of ICT for health promotion among social service organizations with comprehensive evaluation are warranted.

Training to implement a community program has positive effects on health promoters: JC FAMILY Project.

To ease the shortage of professionals, lay volunteers were trained to become health promoters and role models for a large community program to enhance physical activity, well-being, and neighborhood cohesion in socioeconomically disadvantaged groups in Hong Kong. This study aimed to examine the effects on health promoters (trainees) and the feasibility and acceptability of capability-building train-the-trainer workshops (TTTs) using Zero-time Exercise (ZTEx) to implement a community program for about 1,000 participants. A four-session (totally 8 hours) TTT introduced an evidence-based ZTEx intervention to enhance physical activity and well-being, and build capacity for community program implementation. Twenty-eight trainees actively participated in the TTT. Twenty-five and 21 trainees completed the 1- and 3-month questionnaires, respectively. Eleven trainees attended the 1-year focus group interview. Repeated measures analysis of variance and Friedman test were used to compare the parametric and nonparametric data, respectively. Qualitative data were analyzed using thematic content analysis. The trainees reduced their sedentary behavior and improved their interpersonal communication skills, knowledge, and attitude toward ZTEx, grip strength, balance, and perceived well-being. The community participants reported improvements in neighborhood cohesion and grip strength. The 1-year qualitative results supported the 3-month quantitative findings. This brief and innovative TTT affirmed the feasibility of using ZTEx and the role modeling approach for lay health promoters to reduce sedentary behavior and enhance physical activity, fitness, and well-being. They then contributed to the successful implementation of community programs that benefited many. This study provides a new model for building capacity for health promotion in the community.

Development and evaluation of a training workshop for lay health promoters to implement a community-based intervention program in a public low rent housing estate: The Learning Families Project in Hong Kong.

This paper presents the development and evaluation of the train-the-trainer (TTT) workshop for lay resident leaders to be lay health promoters. The TTT workshop aimed to prepare the trainees to implement and/or assist in conducting a series of community-based family well-being activities for the residents in a public low rent housing estate, entitled "Learning Families Project", under the FAMILY project. The four-hour TTT workshop was conducted for 32 trainees (72% women, 43% aged ≥ 60, 41% ≤ elementary school education). The workshop aimed to promote trainees' knowledge, self-efficacy, attitude and practice of incorporating the positive psychology themes into their community activities and engaging the residents to join these activities and learn with their family members. Post-training support was provided. The effectiveness of the TTT was examined by self-administered questionnaires about trainees' reactions to training content, changes in learning and practice at three time points (baseline, and immediately and one year after training), and the difference in residents' survey results before and after participating in the community activities delivered by the trainees. The trainees' learning about the general concepts of family well-being, learning family, leadership skills and planning skills increased significantly with medium to large effect sizes (Cohen's d: 0.5-1.4) immediately after the training. The effects of perceived knowledge and attitude towards practice were sustained to one year (Cohen's d: 0.4-0.6). The application of planning skills to implement community activities was higher at one year (Cohen's d: 0.4), compared with baseline. At one year, the residents' survey results showed significant increases in the practice of positive communication behaviours and better neighbour cohesions after joining the family well-being activities of LFP. Qualitative feedback supported the quantitative results. Our TTT workshop could serve as a practical example of development and evaluation of training programs for lay personnel to be lay health promoters. TRIAL REGISTRATION: ClinicalTrials.gov NCT02844244.

An Evaluation of a Train-the-Trainer Workshop for Social Service Workers to Develop Community-Based Family Interventions.

INTRODUCTION: Evaluation studies on train-the-trainer workshops (TTTs) to develop family well-being interventions are limited in the literature. The Logic Model offers a framework to place some important concepts and tools of intervention science in the hands of frontline service providers. This paper reports on the evaluation of a TTT for a large community-based program to enhance family well-being in Hong Kong. METHODS: The 2-day TTT introduced positive psychology themes (relevant to the programs that the trainees would deliver) and the Logic Model (which provides a framework to guide intervention development and evaluation) for social service workers to guide their community-based family interventions. The effectiveness of the TTT was examined by self-administered questionnaires that assessed trainees' changes in learning (perceived knowledge, self-efficacy, attitude, and intention), trainees' reactions to training content, knowledge sharing, and benefits to their service organizations before and after the training and then 6 months and 1 year later. Missing data were replaced by baseline values in an intention-to-treat analysis. Focus group interviews were conducted approximately 6 months after training. RESULTS: Fifty-six trainees (79% women) joined the TTT. Forty-four and 31 trainees completed the 6-month and 1-year questionnaires, respectively. The trainees indicated that the workshop was informative and well organized. The TTT-enhanced trainees' perceived knowledge, self-efficacy, and attitudes toward the application of the Logic Model and positive psychology constructs in program design. These changes were present with small to large effect size that persisted to the 1 year follow-up. The skills learned were used to develop 31 family interventions that were delivered to about 1,000 families. Qualitative feedback supported the quantitative results. CONCLUSION: This TTT offers a practical example of academic-community partnerships that promote capacity among community social service workers. Goals included sharing basic tools of intervention development and evaluation, and the TTT offered, therefore, the potential of learning skills that extended beyond the lifetime of a single program. CLINICAL TRIAL REGISTRATION: The research protocol was registered at the National Institutes of Health (identifier number: NCT01796275).

Development and Evaluation of a Train-the-Trainer Workshop for Hong Kong Community Social Service Agency Staff.

INTRODUCTION: Capacity building approaches are useful in large-scale community-based health promotion interventions. However, models to guide and evaluate capacity building among social service agency staff in community settings are rare in the literature. This paper describes the development and evaluation of a 1-day (7 h) train-the-trainer (TTT) workshop for the "Enhancing Family Well-Being Project". The workshop aimed at equipping staff from different community agencies with the knowledge and skills to design, implement, and evaluate positive psychology-based interventions for their clients in Sham Shui Po, an over-crowded and low-income district in Hong Kong. METHODS: The current TTT extended and improved on our previous successful model by adding research and evaluation methods (including the Logic Model, process evaluation, and randomized controlled trial), which are important to plan and evaluate the community interventions. Evaluation of the TTT was guided by the Integrated Model of Training Evaluation and Effectiveness (IMTEE), with quantitative and qualitative methods. Quantitative data were collected from pretraining (T1), post-training (T2), and 6-month (T3) and 12-month (T4) follow-up surveys. Qualitative data were collected from four focus groups of agency staff after the intervention. RESULTS: Ninety-three staff from 30 community agencies attended the training, and 90 completed the baseline survey. Eighty-eight, 63, and 57 staff performed the evaluations at T2, T3, and T4, respectively. Agency staff were satisfied with the TTT. Immediate enhancement of knowledge, self-efficacy, and positive attitudes toward the training content was found at T2 (Cohen's d ranged from 0.24 to 1.22, all p < 0.05). Enhancement of knowledge of all training contents persisted at T3 and T4 (Cohen's d ranged from 0.34 to 0.63, all p < 0.05). Enhancement of self-efficacy in the use of positive psychology in intervention design persisted at T3 (Cohen's d = 0.22, p = 0.04). The skills learned were utilized to plan and develop subsequent interventions. Twenty-nine interventions were successfully designed and implemented by the agency staff, and delivered to 1,586 participants. The agency staff indicated their intention to utilize the skills they had learned for other interventions (score ≥4 out of 6) and to share these skills with their colleagues. Qualitative feedbacks from 23 agency staff supported the quantitative results. CONCLUSION: Our brief TTT was effectively delivered to a large number of agency staff and showed effects that persisted up to 12 months. Our training and evaluation models may offer a template for capacity building among social service agency staff for community brief, universal family health promotion interventions in diverse settings.

Development and Two-Year Follow-Up Evaluation of a Training Workshop for the Large Preventive Positive Psychology Happy Family Kitchen Project in Hong Kong.

Evidence-based practice and capacity-building approaches are essential for large-scale health promotion interventions. However, there are few models in the literature to guide and evaluate training of social service workers in community settings. This paper presents the development and evaluation of the "train-the-trainer" workshop (TTT) for the first large scale, community-based, family intervention projects, entitled "Happy Family Kitchen Project" (HFK) under the FAMILY project, a Hong Kong Jockey Club Initiative for a Harmonious Society. The workshop aimed to enhance social workers' competence and performance in applying positive psychology constructs in their family interventions under HFK to improve family well-being of the community they served. The two-day TTT was developed and implemented by a multidisciplinary team in partnership with community agencies to 50 social workers (64% women). It focused on the enhancement of knowledge, attitude, and practice of five specific positive psychology themes, which were the basis for the subsequent development of the 23 family interventions for 1419 participants. Acceptability and applicability were enhanced by completing a needs assessment prior to the training. The TTT was evaluated by trainees' reactions to the training content and design, changes in learners (trainees) and benefits to the service organizations. Focus group interviews to evaluate the workshop at three months after the training, and questionnaire survey at pre-training, immediately after, six months, one year and two years after training were conducted. There were statistically significant increases with large to moderate effect size in perceived knowledge, self-efficacy and practice after training, which sustained to 2-year follow-up. Furthermore, there were statistically significant improvements in family communication and well-being of the participants in the HFK interventions they implemented after training. This paper offers a practical example of development, implementation and model-based evaluation of training programs, which may be helpful to others seeking to develop such programs in diverse communities.

A pathway underlying the impact of CPAP adherence on intimate relationship with bed partner in men with obstructive sleep apnea.

PURPOSE: Our aim was to determine the pathway underlying the effects of continuous positive airway pressure (CPAP) adherence on intimate relationship with bed partner in men with obstructive sleep apnea (OSA). We hypothesized that CPAP with good adherence affected the intimate relationship with bed partner directly and indirectly, and it was mediated through daytime sleepiness and activity level in men with OSA. METHODS: Data were obtained from an education program for enhancing CPAP adherence. Men who were newly diagnosed of OSA and CPAP therapy naïve were recruited in a tertiary teaching hospital. RESULTS: Self-reported quality of life [Functional Outcomes of Sleep Questionnaire], daytime sleepiness [Epworth Sleepiness Scale (ESS)], and negative emotion symptoms [depression, anxiety, stress scale] were assessed before and after CPAP treatment at 1-year assessment. Seventy-three men were included in the data analysis, with a mean ± SD age of 52 ± 10 years, body mass index of 29.0 ± 5.2 kg/m(2), ESS of 9.5 ± 5.6, and median [interquartile range(IR)] apnea and hypopnea index of 31 (21, 56) events/h. The median (IR) CPAP daily usage was 4.3(0, 6.1) h/day. From the path analysis, CPAP therapy was shown to improve intimate relationship directly (ß = 0.185) and indirectly (ß = 0.050) by reducing daytime sleepiness and increasing activity level. However, negative emotion symptoms were not the mediators between CPAP adherence and the intimate relationship. CONCLUSIONS: CPAP therapy with good adherence is related directly and indirectly to a better intimate relationship with bed partner in men with OSA. It was possibly attributed to reduced daytime sleepiness and increased activity level.

The efficacy of a brief motivational enhancement education program on CPAP adherence in OSA: a randomized controlled trial.

BACKGROUND: Poor adherence to CPAP treatment in OSA adversely affects the effectiveness of this therapy. This randomized controlled trial (RCT) examined the efficacy of a brief motivational enhancement education program in improving adherence to CPAP treatment in subjects with OSA. METHODS: Subjects with newly diagnosed OSA were recruited into this RCT. The control group received usual advice on the importance of CPAP therapy and its care. The intervention group received usual care plus a brief motivational enhancement education program directed at enhancing the subjects' knowledge, motivation, and self-efficacy to use CPAP through the use of a 25-min video, a 20-min patient-centered interview, and a 10-min telephone follow-up. Self-reported daytime sleepiness adherence-related cognitions and quality of life were assessed at 1 month and 3 months. CPAP usage data were downloaded at the completion of this 3-month study. RESULTS: One hundred subjects with OSA (mean ± SD, age 52 ± 10 years; Epworth Sleepiness Scales [ESS], 9 ± 5; median [interquartile range] apnea-hypopnea index, 29 [20, 53] events/h) prescribed CPAP treatment were recruited. The intervention group had better CPAP use (higher daily CPAP usage by 2 h/d [Cohen d = 1.33, P < .001], a fourfold increase in the number using CPAP for ≥ 70% of days with ≥ 4 h/d [P < .001]), and greater improvements in daytime sleepiness (ESS) by 2.2 units (P = .001) and treatment self-efficacy by 0.2 units (P = .012) compared with the control group. CONCLUSIONS: Subjects with OSA who received motivational enhancement education in addition to usual care were more likely to show better adherence to CPAP treatment, with greater improvements in treatment self-efficacy and daytime sleepiness. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT01173406; URL: www.clinicaltrials.gov.

Linguistic and psychometric validation of the Chinese version of the self-efficacy measures for sleep apnea questionnaire.

OBJECTIVES: The self-efficacy measure for sleep apnea (SEMSA) questionnaire was shown to be an effective tool to assess adherence-related cognitions on continuous positive airway pressure (CPAP) therapy in obstructive sleep apnea (OSA) subjects. SEMSA helps to solicit fundamental information for formulating strategies to promote CPAP adherence for better treatment outcomes. The objective of our study was to perform a linguistic and psychometric evaluation of a Chinese version of the SEMSA (SEMSA-C). METHODS: Data were obtained from 100 subjects in a randomized controlled trial (RCT) on CPAP education. Subjects were newly diagnosed of OSA and naïve to CPAP therapy. RESULTS: A 26-item SEMSA-C was obtained by a rigorous linguistic validation process. Internal consistency was high with Cronbach α>0.88. One-week test-retest intraclass correlation coefficient (ICC) ranged from 0.70 to 0.82. Principal component factor analysis identified three of the same hypothesized factors (perceived risks, outcome expectancies, and treatment self-efficacy) as in the original version. CPAP adherence was associated with outcome expectancies and treatment self-efficacy at 3-month assessment. Further, SEMSA-C demonstrated an improvement in self-efficacy after CPAP use. CONCLUSIONS: SEMSA-C shows similar psychometric properties as the original English version. It is a reliable and responsive instrument to measure perceived risks, outcome expectancies, and treatment self-efficacy in Chinese subjects with OSA.

Increased serum levels of advanced glycation end-products is associated with severity of sleep disordered breathing but not insulin sensitivity in non-diabetic men with obstructive sleep apnoea.

BACKGROUND: Patients with diabetes mellitus are known to have increased serum levels of advanced glycation end-products (AGEs), and this is also associated with insulin resistance. This study aimed to investigate the relationship between serum AGEs and insulin sensitivity in non-diabetic subjects with obstructive sleep apnoea (OSA). METHODS: Adult males with no known comorbidities were recruited from the sleep clinic of a university teaching hospital. They underwent overnight in-laboratory polysomnography. Fasting blood was taken to measure serum AGE and plasma glucose levels. Insulin sensitivity was estimated using the short insulin tolerance test. RESULTS: In total, 105 subjects with a mean age of 43.5 (standard deviation [SD] 9.2)years, mean body mass index of 27.1 (SD 4.0)kg/m(2), and median apnoea-hypopnoea index (AHI) of 17 (interquartile range 5-46) were analysed. Serum AGE levels were significantly higher in subjects with OSA (AHI ≥5), compared with those without OSA (AHI <5) (3.9 [SD 1.2] vs. 3.2 [SD 0.8]µg/ml, respectively; P=0.037) after adjusting for confounders. AGE levels were positively correlated with AHI (r=0.318, P=0.001), but not with insulin sensitivity. AGE levels decreased in subjects with moderate-to-severe OSA who received continuous positive airway pressure (CPAP) treatment for three months (n=18, P=0.017). CONCLUSIONS: Serum AGE levels correlate with AHI in non-diabetic adult males. This relationship cannot be explained by insulin sensitivity. Supporting the hypothesis of a direct relationship between AHI and AGEs, AGE levels were found to decline with CPAP therapy.

The efficacy of oral appliances in the treatment of severe obstructive sleep apnea.

OBJECTIVES: The purpose of this study is to evaluate the efficacy of oral appliance (OA) treatment for subjects with severe obstructive sleep apnea (OSA) and to determine the dental parameters associated with treatment outcomes. STUDY DESIGN: This study uses a prospective longitudinal design. METHODS: Consecutive Chinese subjects with severe OSA who refused continuous positive airway pressure treatment were recruited. Their dental measurements were taken from lateral cephalometric radiographs. Polysomnograms with OA were repeated at 3 months and 1 year. Blood pressure was taken in the morning after sleep studies. RESULTS: Thirty-four subjects were evaluated at 3 months and 1 year according to the principle of intention-to-treat analysis. OA reduced AHI significantly in subjects with favorable responses, from 49.3 (37.4-67) to 12.5 (6.1-15.7), p < 0.001 at 3 months and from 47.5 (41.1-72.9) to 13.1 (6.0-14.0), p < 0.001 at 1 year. These OSA subjects had an increased overjet at baseline compared to those with unfavorable responses (p ≤ 0.05). Systolic blood pressure was significantly reduced in those hypertensive OSA subjects after 3 months and 1 year of treatment. CONCLUSIONS: OA reduces the severity of sleep apnea, and the effect is maintained at 1 year in subjects with retrognathism. OA appears to reduce systolic blood pressure in hypertensive OSA subjects at 3 months and 1 year.

Determinants of daytime blood pressure in relation to obstructive sleep apnea in men.

This study investigated the roles of different potential pathophysiological mechanisms in the determination of blood pressure in relation to obstructive sleep apnea. The study was designed as a cross-sectional study. Consecutive healthy male subjects who were to undergo polysomnography were recruited. Demographic and anthropometric data were collected. Blood pressure measurements were taken in the evening before sleep and the next morning on waking. Overnight urinary samples for catecholamines and fasting blood for cortisol, insulin, glucose, and lipids were taken. Ninety-four men were analyzed, with a mean age of 43.7 +/- 9.3 years and mean apnea-hypopnea index (AHI) of 27.5 +/- 26.2 events/h. Sixty-nine patients (73%) had obstructive sleep apnea (AHI >or= 5). Urinary catecholamines were positively correlated with severity of sleep apnea, independent of obesity. Blood pressure measurements correlated with age, obesity, severity of sleep apnea, and urinary catecholamines. Regression analysis showed that sleep indices and urinary catecholamines were independent determinants of morning systolic and diastolic blood pressure, respectively, while total cholesterol and waist circumference were respective additional factors. Urinary catecholamines and waist circumference were determinants of evening blood pressure, with morning cortisol being an additional determinant for diastolic blood pressure. Obstructive sleep apnea and related sympathetic activity contributed significantly to the determination of daytime blood pressure in overweight middle-aged men without overt cardiometabolic diseases, and other contributing factors include abdominal obesity, total cholesterol, and cortisol levels.