The Impact of Patient Preference on Attendance and Completion Rates at Centre-Based and mHealth Pulmonary Rehabilitation: A Non-Inferiority Pragmatic Clinical Trial.

Purpose: Pulmonary rehabilitation (PR) is vital in the management of chronic respiratory disorders (CRDs) although uptake, attendance and completion are poor. Differing models of delivering PR are emerging in an attempt to increase the uptake and completion of this intervention. This study aimed to evaluate participant rate of attendance and completion of PR when given a preference regarding model of delivery (centre-based and mPR). Secondary aims were to evaluate the factors affecting patient preference for model of delivery and determine whether mPR is non-inferior to centre-based PR in health outcomes. Methods: A multi-centre non-inferiority preference based clinical trial in Auckland, New Zealand. Participants with a CRD referred for PR were offered the choice of centre-based or mHealth PR (mPR). The primary outcome was completion rate of chosen intervention. Results: A total of 105 participants were recruited to the study with 67 (64%) preferring centre-based and 38 (36%) mPR. The odds of completing the PR programme were higher in the centre-based group compared to mPR (odds ratio 1.90 95% CI [0.83-4.35]). Participants opting for mPR were significantly younger (p = 0.002) and significantly more likely to be working (p = 0.0001). Results showed that mPR was not inferior to centre-based regarding changes in symptom scores (CAT) or time spent in sedentary behaviour (SBQ). When services were forced to transition to telehealth services during COVID-19 restrictions, the attendance and completion rates were higher with telephone calls and video conferencing compared to mPR - suggesting that synchronous interpersonal interactions with clinicians may facilitate the best attendance and completion rates. Conclusion: When offered the choice of PR delivery method, the majority of participants preferred centre-based PR and this facilitated the best completion rates. mPR was the preferred choice for younger, working participants suggesting that mPR may offer a viable alternative to centre-based PR for some participants, especially younger, employed participants.

RE-AIM Analysis of a School-Based Nutrition Education Intervention in Kindergarteners.

BACKGROUND: Few nutrition interventions in kindergarten classes have been evaluated, and none has been tested for program effectiveness, implementation, and dissemination. Building a Healthy Me (BHM) is a nutrition intervention for kindergarteners that is classroom-based and includes a family component. This study evaluated the public health impact of BHM in California kindergarten classrooms using the RE-AIM (reach, efficacy, adoption, implementation, and maintenance) framework. METHODS: A quasi-experimental design assessed pre-to-post changes in nutrition knowledge, dietary consumption, and parent behaviors of 25 intervention classrooms (414 students, 264 parents); and postintervention differences in nutrition knowledge between the intervention classrooms and 4 control classrooms measured at postintervention only (103 students). RESULTS: Intervention students improved in knowledge of food groups and healthy breakfast/snack options, and scored higher than control students in food group knowledge at postintervention (ps < .05). Parents of intervention group children increased their use of food labels, and intervention group children increased intake of several healthy foods and decreased intake of candy and fried potatoes (ps < .05). The BHM program reached 41% of kindergarteners attending public schools in California, and teachers implemented most lesson material. CONCLUSIONS: The BHM program was effective, implemented with fidelity, and broadly disseminated, highlighting its potential public health impact for kindergarteners.

Systematically Improving Tobacco Cessation Patient Services Through Electronic Medical Record Integration.

The Health Information Act of 2010 has presented an opportunity to discuss, establish, and promote innovative ways to incorporate tobacco cessation assistance to patients in the health care setting. This article provides an overview of the development and implementation of an electronic tobacco cessation protocol (the eTobacco protocol), into an electronic medical record (EMR) system, while evaluating the barriers and benefits encountered. The protocol was developed to facilitate the process of electronically referring patients to a state-funded quitline service by establishing a one-click connect for providers to use within the EMR system. While evaluating the implementation of the protocol, findings indicate that several barriers were encountered including disruption of clinic workflow, EMR limitations, and training complications. In spite of the barriers, the protocol shows promising results by increasing referrals to the quitline from 7 patients the year prior to implementation to 1,254 patients after the implementation of the electronic solution. Health care systems that have the ability to modify their EMR system can help lower tobacco use rates among their patients while meeting Meaningful Use requirements. Future research should examine if referrals through the eTobacco protocol are directly associated with patients' tobacco cessation rates.

RE-AIM analysis of a randomized school-based nutrition intervention among fourth-grade classrooms in California.

Childhood overweight and obesity are major health problems. School-based programs enable intervening with large groups of children, but program overall health impact is rarely completely assessed. A RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) analysis tested the overall public health impact of the fourth-grade "Nutrition Pathfinders" school-based nutrition-education program. A randomized controlled trial in 47 fourth-grade California classrooms (1713 students) tested program efficacy, and a secondary analysis of archival data tested program dissemination. Desired effects were seen in child nutrition knowledge, attitudes, consumption of low-nutrient high-density foods, sugar-sweetened beverages, proteins, grains, and parent willingness to serve new foods. The program was disseminated to ∼25 % of public school fourth-grade classrooms in California and cost about $1.00 per student to implement. The Nutrition Pathfinders program demonstrates potential for moderate to high public health impact due to its wide dissemination, effectiveness in altering attitudes and behaviors, and its relatively inexpensive cost of implementation.

Society of Behavioral Medicine (SBM) position statement: SBM supports retaining healthy school lunch policies.

Schools are recognized as venues for population-based health promotion and chronic disease prevention initiatives targeting children, and the school food environment is a central component. The Healthy, Hunger-Free Kids Act of 2010 utilized research-based findings and expert recommendations to significantly improve school lunch standards in the kindergarten to twelfth grade (K-12) setting to enhance the nutritional intake and ultimately the health of children. The new guidelines include increasing the availability of whole grains, fruits, and vegetables; requiring children to select a fruit or vegetable daily; and restricting serving sizes. There is currently no evidence that the revised standards have increased school lunch plate waste. However, there is evidence that children are consuming more healthful foods. The Society of Behavioral Medicine (SBM) supports retaining current school lunch standards set by the Healthy, Hunger-Free Kids Act of 2010. SBM also supports increasing the evidence-based by evaluating the implementation and impact of the school lunch revisions.

Four Dietary Items of the School Physical Activity and Nutrition (SPAN) Questionnaire Form a Robust Latent Variable Measuring Healthy Eating Patterns.

OBJECTIVE: Evaluate the factor structure and stability of 4 dietary items (fruit, fruit juice, vegetables, and milk) from the School Physical Activity and Nutrition questionnaire-elementary school version. METHODS: Secondary analysis of intervention data from third graders measured at pre-intervention, post-intervention (10 weeks), and 3-month follow-up. The researchers conducted structural equation modeling invariance analysis to test the stability of the factor structure of the 4 items. RESULTS: Data from 1,147 students. Fit indices revealed good fit for a single factor remaining stable across time (χ(2)/degrees of freedom [DF] = 59.75/59, P = .45), gender (χ(2)/DF = 149.72/128, P = .09), and study groups (χ(2)/DF = 143.04/128, P = .17). CONCLUSIONS AND IMPLICATIONS: A healthy food factor consisting of the 4 items can be used in future data analysis. This offers several advantages in analysis, including the use of latent change scores that are more powerful, more informative, and more easily interpreted than traditional approaches.

Nutrition self-efficacy is unidirectionally related to outcome expectations in children.

OBJECTIVE: To clarify the underlying relationship between nutrition self-efficacy and outcome expectations because the direction of the relationship (unidirectional vs bidirectional) is debated in the literature. METHODS: Secondary data analysis of a 10-week, 10-lesson school-based nutrition education intervention among 3rd grade students (N = 952). Nutrition self-efficacy (7 items) and nutrition outcome expectations (9 items) were measured through student self-report at intervention pre- (time 1) and post- (time 2) assessments. A series of two time point, multi-group cross-lagged bivariate change score models were used to determine the direction of the relationship. RESULTS: A cross lag from nutrition self-efficacy at time 1 predicting changes in nutrition outcome expectations at time 2 significantly improved the fit of the model (Model 3), whereas a cross lag from nutrition outcome expectations at time 1 to changes in nutrition self-efficacy at time 2 only slightly improved the fit of the model (Model 2). Furthermore, adding both cross lags (Model 4) did not improve model fit compared to the model with only the self-efficacy cross lag (Model 3). Lastly, the nutrition outcome expectations cross lag did not significantly predict changes in nutrition self-efficacy in any of the models. CONCLUSIONS: Data suggest that there is a unidirectional relationship between nutrition self-efficacy and outcome expectations, in which self-efficacy predicts outcome expectations. Therefore, theory-based nutrition interventions may consider focusing more resources on changing self-efficacy because it may also lead to changes in outcome expectations as well.

State-wide dissemination of a school-based nutrition education programme: a RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) analysis.

OBJECTIVE: The current study evaluated the overall public health impact of the 'Shaping Up My Choices' (SMC) programme, a 10-week school-based nutrition education curriculum developed for third-grade students, using the RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) framework. DESIGN: Randomized controlled trial to evaluate the programme and secondary analysis of archival data to describe dissemination. Data were collected from programme records, teacher surveys and student pre-, post- and 3-month follow-up surveys. SETTING: Public elementary schools in California. SUBJECTS: An evaluation sample (938 students and nineteen teachers) and a dissemination sample (195 245 students and 7359 teachers). RESULTS: In the evaluation sample, differences between the control and intervention groups were observed for nutrition knowledge, self-efficacy, outcome expectancies, and intakes of vegetables, fruit (girls only), soda, and low-nutrient high-energy foods from pre- to post-survey. Group differences in change in knowledge, outcome expectancies and vegetable intake were sustained through the 3-month follow-up (efficacy). One hundred per cent of intervention teachers in the evaluation sample implemented all of the lessons (implementation). The dissemination sample represented 42% of third-grade students (reach) and 39% of third-grade classrooms in public elementary schools in California during 2010-2011 (adoption). Thirty-seven per cent of third-grade teachers in the dissemination sample reordered SMC materials during the subsequent school year (2011-2012; maintenance). CONCLUSIONS: The SMC programme demonstrates the potential for moderate to high public health impact.

Who uses snus? A study of Texas adolescents.

INTRODUCTION: Snus, a smokeless tobacco product, was introduced in the United States in 2006. Because it is available in a variety of flavors and is relatively easy to conceal, snus might be particularly attractive to adolescents. Yet, no studies have examined snus use in U.S. adolescents. This brief report examined (a) differences between adolescent snus users and non-snus users on a variety of demographic, behavioral, and intrapersonal factors and (b) prevalence of snus use among current users of various other tobacco products versus nontobacco users. METHODS: Participants were 8,472 6th- to 12th-grade students who voluntarily completed the 87-item Texas Youth Tobacco Survey during class time. RESULTS: Overall, 7.1% of students reported ever trying snus; of these, 77% were male, 68% were in high school, and 46% were White. Mixed-effects regression models indicated that the prevalence of cigarette, chew, cigar, and alcohol use was higher among snus users than among non-snus users. Compared with non-snus users, snus users performed more poorly in school and perceived snus, cigarettes, chew, and cigars to be less dangerous. Finally, current users of cigarettes, chew, and cigars had a higher prevalence of snus use than did their peers who did not use the respective products. CONCLUSIONS: Among U.S. adolescents, snus use may be part of a constellation of health compromising behaviors. Additional research is needed to determine who is using snus and identify the determinants and consequences of snus use, all of which can inform interventions and policies aimed at decreasing tobacco use among youth.

The Personal Nutrition Planner: a 5-week, computer-tailored intervention for women.

OBJECTIVE: To conduct a dietary intervention using the Personal Nutrition Planner (PNP), an on-line nutrition intervention tool. DESIGN: Randomized controlled trial with pretest, posttest, and 2-month follow-up self-report assessments. SETTING: Web/on-line. PARTICIPANTS: Female university staff (n = 307; 59.1% Caucasian) recruited via e-mail. Retention rate was 85.0% (118 treatment; 143 comparison). INTERVENTION: PNP on-line produces individualized nutrition feedback based on initial on-line assessment. Intervention lasted 5 weeks and included weekly e-mail reminders. MAIN OUTCOME MEASURES: Dietary intake frequencies, weight loss, opinions regarding intervention. ANALYSIS: Repeated-measures analysis of variance to determine intervention effects on dietary intake and weight loss (P < .05). RESULTS: Relative to the comparison group who received no program, the treatment group increased dairy intake frequency across the 3 assessments (F(2,304) = 3.15; P < .05). Among participants who wanted to lose weight, weight loss in the treatment group was significantly higher than that of the comparison group from pretest to posttest (F(1,92) = 4.50; P < .05). On a scale of 1-5, mean ratings of the PNP program characteristics ranged from 3-4. CONCLUSIONS AND IMPLICATIONS: PNP produced significant increases in dairy intake and decreases in weight. Further revisions will tailor PNP to better fit individuals' dietary goals and increase motivation.

African American Women's Preparation for Childbirth From the Perspective of African American Health-Care Providers.

Preparation for birthing has focused primarily on Caucasian women. No studies have explored African American women's birth preparation. From the perceptions of 12 African American maternity health-care providers, this study elicited perceptions of the ways in which pregnant African American women prepare for childbirth. Focus group participants answered seven semistructured questions. Four themes emerged: connecting with nurturers, traversing an unresponsive system, the need to be strong, and childbirth classes not a priority. Recommendations for nurses and childbirth educators include: (a) self-awareness of attitudes toward African Americans, (b) empowering of clients for birthing, (c) recognition of the role that pregnant women's mothers play, (d) tailoring of childbirth classes for African American women, and (e) research on how racism influences pregnant African American women's preparation for birthing.

Validation of two food frequency questionnaires for dietary calcium assessment.

Easily utilized questionnaires estimating dietary calcium intake would be a valuable asset to promoting skeletal health as well as a helpful research tool. Two calcium questionnaires, one online and one printed, were each compared with dietary calcium intake measured by a 3-day diet record. Women completed the questionnaires in a randomized order and kept a 3-day food record at home, returning it by mail. The ethnicity of the 140 female study participants was 102 white, 12 African American, 16 Asian, and 10 Latina. The mean age (+/-standard deviation) was 49+/-15 years, with a range of 22.7 to 89.9 years. Measures used included an online calcium quiz, a printed calcium food frequency questionnaire, and one 3-day diet record. Data analysis was done using Pearson correlation coefficients. Sub-analyses were conducted by ethnicity. The correlation between each questionnaire and the daily calcium intake from the diet records was 0.37, P<0.001. Among the ethnic subgroups, the correlations were highest for African-American women, followed by white women. There was also a trend toward higher correlations in younger women. These simple calcium assessment tools, taking fewer than 5 minutes to complete, have correlation values with diet records similar to more complex food frequency questionnaires reported in the literature. These questionnaires may provide valuable tools to estimate calcium intake in research, clinical, and community settings.

Using the RE-AIM framework to evaluate the statewide dissemination of a school-based physical activity and nutrition curriculum: "Exercise Your Options".

PURPOSE: Examine the reach, efficacy, adoption, implementation, and maintenance of a physical activity and nutrition curriculum for middle-school students. DESIGN: Nonexperimental pilot evaluation of a statewide dissemination trial. SETTING: California middle schools during the 2006 to 2007 school year. SUBJECTS: Sixteen classes (N = 668 students and 16 teachers) sampled from the statewide pool who used the program. INTERVENTION: An eight-lesson nutrition and physical activity curriculum, "Exercise Your Options" (EYO), including a teacher guide, video clips, a student activity booklet, and ancillary materials was made available to teachers. MEASURES: Program records, classroom observations, teacher surveys, and student presurveys and postsurveys (assessing physical activity, sedentary behaviors, and dietary intake). ANALYSIS: Descriptive statistics and multilevel random-coefficient modeling. RESULTS: The EYO program reached 234,442 middle-school students in California. During the program, total physical activity increased (p < .001), whereas watching TV/DVDs and playing electronic games/computer use decreased (p < .05). Intake of dairy products increased (p < .05), whereas consumption of sugars/sweets decreased (p < .001). Forty-two percent of eligible middle-school classrooms ordered the program materials. Eighty-six percent of sampled teachers implemented all of the lessons. Over the past 5 years, 51% of all middle-school students in California were exposed to the program. CONCLUSIONS: The EYO program showed its potential for moderate to high public health impact among California middle-school students.

A tailored Internet-plus-email intervention for increasing physical activity among ethnically-diverse women.

OBJECTIVE: To evaluate the feasibility and efficacy of an individually tailored, Internet-plus-email physical activity intervention designed for adult women. METHOD: Healthy and ethnically-diverse adult females (N=156) (mean age=42.8 years, 65% Caucasian) from California were randomly assigned to an intervention (access to a tailored website and weekly emails) or wait-list control group. Participants completed web-based assessments of physical activity, stage of behavior change, and psychosocial variables at baseline, one month, two months, and three months. Data were collected during 2006-2007. Multilevel random coefficient modeling examined group differences in rates of change. RESULTS: As compared to the control condition, the intervention group increased walking (+69 versus +32 min per week) and total moderate-to-vigorous physical activity (+23 versus -25 min per week) after three months. The intervention did not impact stage of behavior change or any of the other psychosocial variables. CONCLUSION: A tailored, Internet-based intervention for adult women had a positive effect on walking and moderate-to-vigorous physical activity in an ethnically-diverse sample. However, given the lack of comparable research contact in the control group, these findings should be taken cautiously.

The role of emotion in mammography screening of African-American women.

Dominant theories that are used to predict health behavior ignore the role played by emotion in peoples decisions to seek preventive health care. This exploratory study describes how the fears of African-American women and their other emotions influence their response to mammography screening interventions. Thirty-seven (N = 37) African-American women in Central and North Texas completed face-to-face interviews and paper and pencil emotion scales. Findings from this study suggest that fear of breast cancer was the predominant emotional theme that emerged. Further findings from this study also suggest that women who had previously had mammograms expressed both stronger negative and positive feelings and emotions than women who had never had mammograms. In addition, women who had never had a mammogram expressed fear of radiation from the mammography equipment, and potential pain related to the procedure, as well as fear of finding out that they might have cancer. Feedback from these African-American study participants suggests that simply to hear a message promoting breast cancer screening is not sufficient to motivate African-American women to seek mammography.

The Expect Respect Project. Creating a positive elementary school climate.

The Expect Respect Project, a violence prevention program, was developed to reduce the incidence of bullying and sexual harassment by creating a positive school climate in which inappropriate behaviors are not tolerated and staff members respond consistently to incidents. The project implemented an educational intervention for students, parents, and staff members on expecting respect in student relationships and strategies for responding to inappropriate student behaviors. This article describes the educational intervention and evaluation of the project. Findings from the project showed a significant increase in awareness of bullying following the educational intervention. Bullying was reported to have occurred in areas with less adult supervision such as the playground, cafeteria, hallway, and buses. Students thought staff would respond to inappropriate behaviors by telling students to ignore verbal bullying or sexual harassment. In contrast, staff at the elementary schools thought adults would respond to inappropriate behaviors by telling the bully to stop, calling his or her parents, or giving a specific punishment.