A randomized controlled trial to prevent obesity among Latino paediatric patients.

BACKGROUND: Obesity disproportionately affects Latino youth. Community clinics are an important resource, yet there is little evidence for the efficacy of clinic-based approaches in this population. OBJECTIVE: The purpose of this study was to test the efficacy of a clinic-based intervention to lower body mass index (BMI) and improve body composition among overweight Latino children. METHODS: A randomized trial (2 group × 3 repeated measures) was conducted among 297 randomly sampled, overweight paediatric patients (5-10 years old) and their parents. The 12-month family-based culturally tailored behavioural intervention (Luces de Cambio) was based on the 'traffic light' concepts to address behaviour change and was delivered by clinic health educators and mid-level providers. The primary study outcome was child BMI (kg m-2 ) assessed at baseline, 6-month (n = 191) and 12-month (n = 201) post-baseline. A subsample of the children was examined for overall and site-specific adiposity using dual-energy X-ray absorptiometry (n = 79). RESULTS: There were no significant intervention effects on child BMI (p > 0.05); however, intervention children showed significantly (p < 0.05) lower total and trunk per cent fat compared with the usual care condition. CONCLUSIONS: The Luces intervention did not reduce child BMI, yet small but significant reductions were observed for child per cent body fat. Further research is needed to identify and reduce barriers to recruitment and participation among Latino families.

Perceived Neighborhood Environmental Factors That Maximize the Effectiveness of a Multilevel Intervention Promoting Physical Activity Among Latinas.

PURPOSE: This study tested whether a multilevel physical activity (PA) intervention had differential effects on PA according to participants' perceptions of their neighborhood environment. DESIGN: Two-group cluster randomized controlled trial. SETTING: San Diego, California. SUBJECTS: Analytical sample included 319 Latinas (18-65 years) from churches randomized to the following conditions: PA (n = 8 churches, n = 157 participants) or attention control (n = 8 churches, n = 162 participants). INTERVENTION: Over 12 months, PA participants were offered free PA classes (6/wk), while attention control participants were offered cancer prevention workshops. MEASURES: Baseline and 12-month follow-up measures included self-report and accelerometer-based moderate to vigorous physical activity (MVPA), sociodemographics, and perceived neighborhood environment variables. ANALYSIS: Mixed-effects models examined each PA outcome at 12-month follow-up, adjusted for church clustering, baseline PA, and sociodemographics. We tested interactions between 7 baseline perceived environment variables and study condition. RESULTS: Neighborhood esthetics was the only significant moderator of intervention effects on accelerometer-based MVPA and self-report leisure-time MVPA. Participants in the PA intervention had significantly higher PA at follow-up than attention control participants, only when participants evaluated their neighborhood esthetics favorably. CONCLUSION: Perceived neighborhood esthetics appeared to maximize the effectiveness of a multilevel PA intervention among Latinas. For sustainable PA behavior change, the environments in which Latinas are encouraged to be active may need to be evaluated prior to implementing an intervention to ensure they support active lifestyles.

Promoting cancer screening among churchgoing Latinas: Fe en Acción/faith in action.

Cancer screening rates among Latinas are generally low, reducing the likelihood of early cancer detection in this population. This article examines the effects of a community intervention (Fe en Acción/Faith in Action) led by community health workers (promotoras) on promoting breast, cervical and colorectal cancer screening among churchgoing Latinas. Sixteen churches were randomly assigned to a cancer screening or a physical activity intervention. We examined cancer knowledge, barriers to screening and self-reported mammography, clinical breast exam, Pap test, fecal occult blood test and sigmoidoscopy or colonoscopy at baseline and 12 months follow-up. Participants were 436 adult Latinas, with 16 promotoras conducting a cancer screening intervention at 8 out of 16 churches. The cancer screening intervention had a significant positive impact on self-reported mammography (OR = 4.64, 95% CI: 2.00-10.75) and breast exams in the last year (OR= 2.82, 95% CI: 1.41-5.57) and corresponding reductions in perceived (87.6%) barriers to breast cancer screening (P < .008). Cervical and colorectal cancer screening did not improve with the intervention. These findings suggest Fe en Acción church-based promotoras had a significant impact on promoting breast cancer screening among Latinas. Colon cancer screening promotion, however, remains a challenge.

Interactions between individual and perceived environmental factors on Latinas' physical activity.

Background: Latinas have disproportionately low levels of physical activity (PA) and the ecological correlates of their PA remain unclear. This study aims to test interactions between individual and environmental factors on Latinas' PA. Methods: We analyzed baseline data from 436 Latinas participating in a PA randomized controlled trial in San Diego, CA [Fe en Acción/Faith in Action]. Measures included demographics, perceived environment, PA and anthropometrics. Mixed effects models examined interactions between individual and environmental factors on self-reported leisure-time and transportation, and accelerometer-assessed PA. Results: Significant positive associations were found between neighborhood aesthetics and leisure-time moderate-to-vigorous PA (MVPA) and between having destinations within walking distance from home and transportation PA (P < 0.05). We found significant interactions of income with aesthetics and sidewalk maintenance as well as between weight status and safety from crime. Favorable aesthetics was related to more leisure-time MVPA only among lower income women (odds ratio (OR) = 1.57; 95% confidence interval (CI): 1.18, 2.08); however, higher income women reporting better sidewalk maintenance reported more leisure-time MVPA (OR = 1.51; 95% CI: 1.06, 2.15). Higher perceived safety from crime was positively related to transportation PA only among overweight/obese women. Conclusions: Subgroup differences should be considered when developing interventions targeting the neighborhood environment to promote Latinas' PA.

Does the social environment moderate associations of the built environment with Latinas' objectively-measured neighborhood outdoor physical activity?

Favorable perceptions of the built and social neighborhood environment may promote outdoor physical activity (PA). However, little is known about their independent and interactive effects on neighborhood-specific outdoor PA. We examined associations of perceived built and social neighborhood environment factors, and their interactions, with objectively-measured neighborhood outdoor moderate-to-vigorous physical activity (MVPA) among a sample of Latina women in San Diego, CA. Analyses included baseline data collected in 2011-2013 from 86 Latinas with ≥ 2 days of combined accelerometer and global positioning system data and complete survey measures. We examined objective neighborhood outdoor MVPA within 500-meter home buffers. Generalized linear mixed models examined associations of 3 perceived built (e.g., sidewalk maintenance) and 3 social environmental (e.g., safety from crime) factors with engaging in any daily neighborhood outdoor MVPA. Models tested interactions between the built and social environmental factors. Although the perceived neighborhood environmental factors were not significantly related to daily neighborhood outdoor MVPA, we found 2 significant interactions: perceived sidewalk maintenance x safety from crime (p = 0.05) and neighborhood aesthetics x neighborhood social cohesion (p = 0.03). Sidewalk maintenance was positively related to daily neighborhood outdoor MVPA only among Latinas that reported low levels of safety from crime. Neighborhood aesthetics was positively related to daily neighborhood outdoor MVPA only among Latinas with high neighborhood social cohesion. Findings suggest several built and social environmental factors interact to influence Latinas' neighborhood outdoor MVPA. Interventions are needed targeting both built and social neighborhood environmental factors favorable to outdoor PA in the neighborhood.

Childhood obesity prevention and control in city recreation centres and family homes: the MOVE/me Muevo Project.

BACKGROUND: Interventions to prevent and control childhood obesity have shown mixed results in terms of short- and long-term changes. OBJECTIVES: 'MOVE/me Muevo' was a 2-year family- and recreation centre-based randomized controlled trial to promote healthy eating and physical activity among 5- to 8-year-old children. It was hypothesized that children in the intervention group would demonstrate lower post-intervention body mass index (BMI) values and improved obesity-related behaviours compared with the control group children. METHODS: Thirty recreation centres in San Diego County, California, were randomized to an intervention or control condition. Five hundred forty-one families were enrolled and children's BMI, diet, physical activity and other health indicators were tracked from baseline to 2 years post-baseline. Analyses followed an intent-to-treat approach using mixed-effects models. RESULTS: No significant intervention effects were observed for the primary outcomes of child's or parent's BMI and child's waist circumference. Moderator analyses, however, showed that girls (but not boys) in the intervention condition reduced their BMI. At the 2-year follow-up, intervention condition parents reported that their children were consuming fewer high-fat foods and sugary beverages. CONCLUSIONS: Favourable implementation fidelity and high retention rates support the feasibility of this intervention in a large metropolitan area; however, interventions of greater intensity may be needed to achieve effects on child's BMI. Also, further research is needed to develop gender-specific intervention strategies so that both genders may benefit from such efforts.

Promoting sun safety among zoo visitors.

BACKGROUND: Each year, millions of children visit zoological parks, where they are exposed to long bouts of ultraviolet radiation (UVR). We conducted a study in the winter and replicated it in the summer to evaluate an intervention for reducing UVR exposure during the zoo visit. METHODS: Each study used a nonequivalent control group design: one zoological site received the intervention and a second received evaluation only. Key outcome measures consisted of observed prevalence of hat use by exiting children (N = 8,721 and 8,524, respectively, in winter and summer studies) and purchase rates of sunscreen and hats in zoo gift shops. Intervention consisted of tip sheets for parents, children's activities, prompts, and discounts off the price of sunscreen and sun-protective hats. RESULTS: In the summer study, sales of both sunscreen and target hats increased significantly at the intervention site relative to the control site, whereas in the winter study, only sunscreen sales at the intervention site had a significant (relative) increase. Children's hat use increased significantly at the intervention site, but only in the winter study. CONCLUSIONS: The multicomponent program was effective in promoting purchases of sun-safe items, but its impact on children's hat use was inconclusive.

Evaluation of a first aid and home safety program for Hispanic migrant adolescents.

BACKGROUND: Unintentional injuries are the major cause of death among children, adolescents, and young adults. This article presents an evaluation of an injury-prevention program for 11- to 16-year-old, Hispanic migrant youth. DESIGN: Randomized controlled trial with two conditions: first aid and home safety training and tobacco and alcohol prevention. Participants were assessed at baseline, at immediate post-intervention, and at 1-year follow-up. PARTICIPANTS: A total of 660 Hispanic adolescent and parent pairs participated in a program entitled Sembrando Salud (sowing the seeds of health). INTERVENTION: The intervention consisted of two conditions: first aid and home safety training and tobacco and alcohol prevention. Both groups were exposed to an eight-session, multimedia program presented by bilingual, bicultural college students. The sessions consisted of lectures, discussions, and skills development and practice. OUTCOME MEASURES: To examine the efficacy of the first aid and home safety intervention, adolescents were assessed for changes in first aid confidence, knowledge of items in a first aid kit, knowledge of how to respond in an emergency situation, acquisition of a first aid kit, and behavioral skills testing in response to two emergency scenarios. RESULTS: Similar changes in confidence were observed in both groups after the intervention. Participants in the first aid and home safety program were better able to identify items to include in a first aid kit, how to respond in an emergency situation, and reported fewer erroneous victim-caring procedures than the tobacco and alcohol prevention group. CONCLUSIONS: Sembrando Salud was successful at achieving and maintaining change in confidence and knowledge of first aid and emergency response skills over a yearlong period.

Ability of fat and fat-free mass percentages to predict functional disability in older men and women.

OBJECTIVES: Previous studies suggest an association between body composition and declining functional ability in older people. This study examined the relation between functional disability and percentage of fat mass (FM) and percentage of fat-free mass (FFM) in older men and women. DESIGN: Cross-sectional and prospective. SETTING: Rancho Bernardo, California. PARTICIPANTS: Subjects consisted of 1,051 ambulatory, community-dwelling Caucasian men and women, age 55 to 92, who attended a clinic visit between 1988 and 1992 and a subsequent clinic visit between 1992 and 1996. MEASUREMENTS: Measured at both visits, percentage of fat mass and percentage of lean body mass were estimated by bioelectric impedance analysis and functional disability was ascertained by self-administered questionnaire. Functional disability was dichotomized into those having any difficulty with a set of tasks versus those having no difficulty with the tasks. Two measures of functional disability were used: "lower body" disability, consisting of two lower motor tasks (walking 2-3 blocks and climbing up 10 stairs) and "overall" disability, consisting of nine tasks representing upper and lower body function and mobility. RESULTS: Compared with men, women were more likely to report both lower body and overall functional disability (P=.001). Cross-sectionally, a significant positive association was shown between fat mass and overall functional disability and a significant negative association was shown between FFM and overall functional disability in both men and women. Prospectively, increased percentage of body fat and decreased percentage of FFM were significantly associated with decreased functional ability in both women and men. All results were adjusted for age, smoking, alcohol use, physical activity, current estrogen use, depression, chronic disease, and education. CONCLUSION: Increased percentage of fat mass and decreased percentage of FFM are associated with greater functional disability in older men and women. Further research is needed to assess the relative importance of decreasing fat percentage or increasing fat-free percentage to preserve or improve functional ability in older people.

Tobacco use and other risk behaviors: cross-sectional and predictive relationships for adolescent orthodontic patients.

BACKGROUND: The purpose of these analyses was to examine the prevalence of selected substance abuse, general and dental health risk, and scholastic risk behaviors and their cross-sectional and predictive relationships with tobacco use among 15, 179 adolescent orthodontic patients in Southern California. METHODS: Subjects were recruited through 154 orthodontists' offices and interviewed by telephone at baseline and two-year posttest. RESULTS: Results show a pattern of increasing prevalence of risk behaviors with age. In most cases, gender differences were small. There were statistically significant positive relationships between each risk behavior and tobacco use status for both boys and girls. Prevalence rates of risk behaviors other than tobacco use were highest for current smokers, intermediate for experimenters, and lowest for respondents reporting that they had never used tobacco. Baseline tobacco use predicted each posttest risk behavior in logistic regression analyses. Principle components analysis (with varimax rotation) of posttest risk practices other than tobacco use yielded three theoretically meaningful factors, all which were predicted by baseline tobacco use in multiple regressions. CONCLUSIONS: These findings show that tobacco use among adolescents can predict subsequent risk practices other than tobacco use as long as two years, and that unhealthy behaviors among teens are interrelated. Orthodontists, who have a high frequency of adolescent patient contact, may be in a unique position to deliver health promotion interventions to their patients; possibly targeting multiple risk behaviors.

Patient reminder letters to promote annual mammograms: a randomized controlled trial.

BACKGROUND: This study assessed the effects of a reminder letter from a physician (relative to a mammography facility letter or no letter) on appointment compliance among women 50-74 years of age due for an annual screening mammogram. METHODS: A total of 1,562 women were randomly as signed to the groups. Each Group 1 subject received a reminder letter from her physician, each Group 2 subject received a reminder letter from her mammography facility, and Group 3 served as a control group. RESULTS: The return rates for Groups 1, 2, and 3 were 47.7, 46.6, and 28.3%, respectively; the overall difference was significant using a chi(2) analysis (P < 0.001). Bonferroni pairwise comparisons indicated no difference between Groups 1 and 2 but significant differences (P < 0.001) between Group 3 and the other two groups. Logistic regression indicated that relative to Group 3, the adjusted odds of returning for Groups 1 and 2 were 2.37 and 2.24, respectively. CONCLUSIONS: Mammography providers and their patients likely will benefit from in-reach reminder systems. Physicians who do not use reminder systems should refer their patients to facilities that use these systems.

Predictors of cigarette and alcohol susceptibility and use among Hispanic migrant adolescents.

BACKGROUND: Little is known about interpersonal and broader sociocultural factors related to protection from or use of tobacco and alcohol among immigrant adolescents. This study presents the baseline predictors of tobacco and alcohol use and susceptibility to tobacco and alcohol among Hispanic migrant adolescents. METHODS: The sample consisted of 660 Hispanic adolescents (51% male) between the ages of 11 and 16 years enrolled in the Migrant Education Program through the County Office of Education. Slightly more than 75% of the study sample was first generation Hispanics and 79% preferred to speak Spanish. An interviewer-administered survey assessed the following information: standard demographic characteristics, modeling of cigarette smoking (including parental and peer smoking), attitudes (including self-standards and anticipated outcomes), acculturation, communication with parents, amount of social support, and satisfaction with social support. RESULTS: Significant predictors of susceptibility to tobacco and smoking status included age, gender, attitudes toward cigarettes (e.g., anticipated outcomes, self-standards), satisfaction with social support, and parent-child communication. Factors that were also significant predictors of susceptibility to alcohol and drinking status were age, attitudes toward drinking, satisfaction with social support, and level of parent-child communication. In addition, peer and household use of alcohol predicted adolescent outcomes. CONCLUSIONS: Based on these results it is suggested that tobacco and alcohol prevention efforts for first-generation Hispanic adolescents should target not only usual concerns (e.g., availability, peer pressure, modeling, expectancies), but also parent-child communication.

Evaluation of a tobacco and alcohol use prevention program for Hispanic migrant adolescents: promoting the protective factor of parent-child communication.

BACKGROUND: Interventions designed to prevent tobacco and alcohol use targeting high-risk adolescents are limited. In addition, few studies have attempted to improve parent-child communication skills as a way of improving and maintaining healthy youth decision-making. METHODS: A total of 660 Hispanic migrant families participated in a randomized pre-post control group study that was utilized to determine the impact of the intervention on parent-child communication. Both treatment and attention-control groups of youth were exposed to an eight-session culturally sensitive program presented by bilingual/bicultural college students. Parents jointly attended three of the eight sessions and participated in helping their child complete homework assignments supporting the content of each session. The content of the treatment intervention included (1) information about tobacco and alcohol effects, (2) social skills training (i.e., refusal skills), and (3) the specific development of parent-child communication skills to support healthy youth decisions. RESULTS: Significant intervention by household size interactions for both parent and youth perceptions of communication were found indicating that the treatment was effective in increasing communication in families with fewer children. Based on the effect size and the previously established relationship between communication and susceptibility to tobacco and alcohol use, it was determined that the intervention effect could be translated into a future 5 to 10% decrease in susceptibility for these smaller families. CONCLUSIONS: A culturally sensitive family-based intervention for migrant Hispanic youth was found to be effective in increasing perceived parent-child communication in families with fewer children. It is expected that increases in this important protective factor will lead to later observed decreases in tobacco and alcohol use.

Children in foster care: factors influencing outpatient mental health service use.

OBJECTIVE: To determine factors influencing outpatient mental health service use by children in foster care. METHOD: Detailed survey and administrative data were collected on 480 children who entered long-term foster care in San Diego County from May 1990 through October 1991. These data were linked with claims data from Medicaid and San Diego County Mental Health Services information systems. A Poisson regression model was used to determine whether the following factors influenced outpatient mental health service use: age, race/ethnicity, gender, maltreatment history, placement pattern, and behavioral problems as measured by the Achenbach Child Behavior Checklist (CBCL). RESULTS: Except for maltreatment history, all independent variables included in the multivariate regression model were statistically significant. The total number of outpatient mental health visits increased with age, male gender, and non-relative foster placements. Relative to Caucasians, visits were lower for Latinos, and Asian/Others, but comparable for African-Americans. Concerning maltreatment history, differences were only found in one category; children experiencing caretaker absence received fewer visits compared to children who did not experience caretaker absence. Children with CBCL Total Problem Scale T-scores of 60 or greater had significantly more visits than those with a score less than 60. CONCLUSIONS: Both clinical and non-clinical factors influence outpatient mental health service use by foster children. Limitations imposed by gender, race/ethnicity, and placement setting need to be addressed by child welfare policies. These finding suggest that guidelines are needed to systematically link children in foster care with behavioral problems to appropriate services.

Counseling youth in tobacco-use prevention: determinants of clinician compliance.

OBJECTIVE: The rate and determinants of tobacco prevention and cessation counseling to youth were examined for orthodontists participating in a controlled trial to decrease the incidence of tobacco use among adolescents. METHODS: A cross-sectional interview design in private practice offices throughout Southern California was used. The survey was completed with 126 (82%) orthodontists. Clinicians randomly assigned to the experimental group (N = 77) received a 1.5 h workshop, anti-tobacco materials, reimbursement for provision of anti-tobacco prescriptions, and quarterly checkup visits. Control group clinicians (N = 77) did not receive training, materials, or visits. RESULTS: Experimental group clinicians talked to more adolescent nonsmokers about never beginning tobacco use than did control group clinicians (P < 0.05). Experimental group clinicians talked to more adolescent tobacco users than did control group clinicians; however, the difference was not statistically significant. Content and determinants of counseling were affected by participation in the intervention. CONCLUSIONS: Though training and support increased prevention and cessation counseling, absolute rates remained less than optimal. Social learning factors were associated with prevention and cessation counseling.

The risk of appendiceal rupture based on hospital admission source.

OBJECTIVE: To determine whether admission source is a potential risk factor for appendiceal rupture. METHODS: Administrative data were obtained from the California Office of Statewide Health Planning and Development for all patients in San Diego County with the primary diagnosis of appendicitis during 1993. The appendiceal rupture ratio was defined as those coded as ruptured (ICD-9-CM codes 540.0 and 540.1) divided by both ruptured and non-ruptured cases (540.9). The odds ratio of appendiceal rupture from routine outpatient office or clinic venues vs those admitted through the ED were calculated using multivariate logistic regression analysis to adjust for age, sex, race, comorbidity, insurance status, and home address to hospital proximity. RESULTS: There were a total of 1,906 patients, of whom 663 (34.8%) had appendiceal ruptures. Of the 1,360 (71.4%) admitted from the ED, 422 (31.0%) had ruptures, compared with 211 (43.3%) of the 487 admitted from outpatient sources (p < 0.0001). Patients with appendicitis directly admitted from outpatient sources were more likely to be complicated by appendiceal rupture than were those admitted through the hospital ED (adjusted odds ratio 1.62, 95% CI = 1.28 to 2.05, p < 0.0001). CONCLUSION: Patients with appendicitis admitted from outpatient sources are more likely to have appendiceal rupture than are those admitted from the ED.

Promoting skin cancer prevention counseling by pharmacists.

OBJECTIVES: This study evaluated the effects of an intervention on rates of skin cancer prevention counseling by pharmacists. METHODS: Fifty-four pharmacies were randomly assigned to intervention or control conditions. Intervention consisted of training, feedback, and prompts. Counseling rates before and after the intervention were obtained from study confederates. RESULTS: At pretest, the proportions of control and intervention sites providing counseling at least once were 7.4% and 0%, respectively (NS). At posttest, these proportions were 3.7% and 66.7%, respectively (P < .001). CONCLUSIONS: The results indicated that the intervention was successful and that pharmacists can play an important role in educating the public about skin cancer prevention strategies.

Skin cancer prevention counseling by pharmacists: specific outcomes of an intervention trial.

The purpose of this study was to evaluate the effects of an intervention on pharmacists' behaviors, knowledge, and attitudes related to skin cancer prevention counseling. Fifty-four pharmacy sites (N = 178 pharmacists) were randomly assigned to the intervention or control condition. Intervention consisted of video-based training, prompts installed in the pharmacy to promote pharmacist-patient discussions on the topic, and group-based feedback on previous week's counseling rates. Outcomes were measured using a mailed survey. The proportion of patients counseled at post-test was significantly higher among intervention subjects, adjusting for pretest values. Similar results were found for pharmacists' skin cancer knowledge and self-rated expertise, but not for counseling-related attitudes. The intervention was successful. If implemented on a wide scale, large segments of the U.S. population would be exposed to skin cancer prevention advice.

Self-perceived health and 5-year mortality risks among the elderly in Shanghai, China.

Studies of the elderly worldwide over the last 3 decades have reported that a self-rating of "poor" compared with "excellent/good" health increases the relative risk of dying. The authors tested the strength of this association by performing age-stratified Cox regression analyses on a 5-year longitudinal study of a representative sample of noninstitutionalized elderly aged 65 years and older (n=3,094) in a district of Shanghai, China. More than 20 potential confounders that were only partially controlled in other studies and threats to response validity due to cognitive impairment or diagnosed dementia that were not considered in previous studies were taken into account in this analysis. The results showed that among those aged 65-74 years, "poor" perceived health increases the adjusted relative risk of death by 1.93 (95% confidence interval 1.20-3.11) compared with "excellent/good" health. The adjusted relative risk of a "fair" rating of health is 2.16 (95% confidence interval 1.44-3.25). In the older age group, mortality risks for the ratings of fair as well as poor compared with excellent/good health were not statistically significant. The authors posit that several mechanisms related to host vulnerability markers and greater-than-expected utilization of health services may explain the association between self-assessed health and mortality risks. Future research should strive to develop more precise measures of these and related variables.

Tracking and follow-up of 16,915 adolescents: minimizing attrition bias.

This paper reports a multi-dimensional approach to minimize drop-outs from a two-year follow-up of a clinical trial designed to reduce initiation of tobacco use in 16,915 adolescent orthodontic patients. A hierarchical approach to data collection and tracking was employed. Seventy percent of participants were reached and interviewed at home by telephone. Strategies used to survey remaining participants included calling parents' work numbers and directory assistance, reviewing orthodontists' charts, sending surveys by mail, offering incentives, and using reverse telephone directories. More than 92% of the participants completed follow-up surveys. Multivariate analyses showed that baseline tobacco and alcohol use predicted loss to follow-up. Similarly, the number of procedures used to track each participant predicted presence of risk behaviors at post-test, demonstrating that an organized tracking hierarchy curtailed even greater compromises to internal and external validity. Evaluation and costs of individual strategies are discussed.