Development of a multi-component intervention to promote participation of Black and Latinx individuals in biomedical research.

INTRODUCTION: Barriers to research participation by racial and ethnic minority group members are multi-factorial, stem from historical social injustices and occur at participant, research team, and research process levels. The informed consent procedure is a key component of the research process and represents an opportunity to address these barriers. This manuscript describes the development of the Strengthening Translational Research in Diverse Enrollment (STRIDE) intervention, which aims to improve research participation by individuals from underrepresented groups. METHODS: We used a community-engaged approach to develop an integrated, culturally, and literacy-sensitive, multi-component intervention that addresses barriers to research participation during the informed consent process. This approach involved having Community Investigators participate in intervention development activities and using community engagement studios and other methods to get feedback from community members on intervention components. RESULTS: The STRIDE intervention has three components: a simulation-based training program directed toward clinical study research assistants that emphasizes cultural competency and communication skills for assisting in the informed consent process, an electronic consent (eConsent) framework designed to improve health-related research material comprehension and relevance, and a "storytelling" intervention in which prior research participants from diverse backgrounds share their experiences delivered via video vignettes during the consent process. CONCLUSIONS: The community engaged development approach resulted in a multi-component intervention that addresses known barriers to research participation and can be integrated into the consent process of research studies. Results of an ongoing study will determine its effectiveness at increasing diversity among research participants.

Healthy Eating Policy Strategies in Community Health Improvement Plans: A Cross-Sectional Survey of US Local Health Departments.

CONTEXT: Policies (eg, regulations, taxes, and zoning ordinances) can increase opportunities for healthy eating. Community Health Improvement Plans (CHIP) may foster collaboration and local health department (LHD) engagement in policy decision making to improve local food environments. Limited research describes what policies supportive of healthy food environments are included in CHIPs nationally and relationships between LHD characteristics and participation in plans including such policies. OBJECTIVES: To determine the proportion of US LHDs who participated in development of a CHIP containing healthy eating policy strategies and assess the association between LHD characteristics and inclusion of any healthy eating policy strategy in a CHIP. DESIGN: A cross-sectional national probability survey. PARTICIPANTS: Of the 209 US LHDs (serving populations <500 000) (response rate: 30.2%), 176 LHDs with complete data on CHIP status, outcomes, and covariates were eligible for analysis. MAIN OUTCOME MEASURES: Thirteen healthy eating policy strategies were organized into 3 categories: increasing availability/identification of healthy foods, reducing access to unhealthy foods, and improving school food environments. Strategies and categories were identified from literature and public health recommendations. RESULTS: In total, 32.2% of LHDs reported inclusion of 1 or more healthy eating policy strategies in a CHIP. The proportion of departments reporting specific strategies ranged from 20.8% for school district policies to 1.1% for sugar-sweetened beverage taxes. Local health departments serving 25 000 to 49 999 residents (odds ratio [OR]: 5.00; 95% confidence interval [CI]: 1.71-14.63), 100 000 to 499 999 residents (OR: 3.66; 95% CI: 1.12-11.95), pursuing national accreditation (OR: 4.46; 95% CI: 1.83-10.83), or accredited (OR: 3.22; 95% CI: 1.08-9.63) were more likely to include 1 or more healthy eating policy strategies in a CHIP than smaller LHDs (<25 000) and LHDs not seeking accreditation, respectively, after adjusting for covariates. CONCLUSIONS: Few LHDs serving less than 500 000 residents reported CHIPs that included a policy-based approach to improve food environments, indicating room for improvement. Population size served and accreditation may affect LHD policy engagement to enhance local food environments.

A REDCap-based model for electronic consent (eConsent): Moving toward a more personalized consent.

INTRODUCTION: The updated common rule, for human subjects research, requires that consents "begin with a 'concise and focused' presentation of the key information that will most likely help someone make a decision about whether to participate in a study" (Menikoff, Kaneshiro, Pritchard. The New England Journal of Medicine. 2017; 376(7): 613-615.). We utilized a community-engaged technology development approach to inform feature options within the REDCap software platform centered around collection and storage of electronic consent (eConsent) to address issues of transparency, clinical trial efficiency, and regulatory compliance for informed consent (Harris, et al. Journal of Biomedical Informatics 2009; 42(2): 377-381.). eConsent may also improve recruitment and retention in clinical research studies by addressing: (1) barriers for accessing rural populations by facilitating remote consent and (2) cultural and literacy barriers by including optional explanatory material (e.g., defining terms by hovering over them with the cursor) or the choice of displaying different videos/images based on participant's race, ethnicity, or educational level (Phillippi, et al. Journal of Obstetric, Gynecologic, & Neonatal Nursing. 2018; 47(4): 529-534.). METHODS: We developed and pilot tested our eConsent framework to provide a personalized consent experience whereby users are guided through a consent document that utilizes avatars, contextual glossary information supplements, and videos, to facilitate communication of information. RESULTS: The eConsent framework includes a portfolio of eight features, reviewed by community stakeholders, and tested at two academic medical centers. CONCLUSIONS: Early adoption and utilization of this eConsent framework have demonstrated acceptability. Next steps will emphasize testing efficacy of features to improve participant engagement with the consent process.

Perceptions of the Built Environment and Support for Policies That Promote Physical Activity.

BACKGROUND: To assess how perceptions of the community built environment influence support for community policies that promote physical activity (PA). METHODS: A national cross-sectional survey assessed perceptions of the local built environment and support of community policies, including school and workplace policies, promoting PA. A random digit-dialed telephone survey was conducted in US counties selected on Behavioral Risk Factor Surveillance System data for high or low prevalence of obesity and inactivity. A total of 1208 subjects were interviewed, 642 from high-prevalence counties and 566 from low-prevalence counties. Analyses were stratified by county prevalence of obesity and inactivity (high or low). Linear models adjusted for covariates were constructed to assess the influence of built environment perceptions on policy support. RESULTS: Perception of more destinations near the residence was associated with increased support for community policies that promote PA, including tax increases in low-prevalence (obesity and inactivity) counties (P < .01). Positive perception of the workplace environment was associated (P < .001) with increased support for workplace policies among those in high-, but not low-, prevalence counties. CONCLUSIONS: Support for community policies promoting PA varies by perception of the built environment, which has implications for policy change.

Developing Core Capabilities for Local Health Departments to Engage in Land Use and Transportation Decision Making for Active Transportation.

OBJECTIVE: To develop a core set of capabilities and tasks for local health departments (LHDs) to engage in land use and transportation policy processes that promote active transportation. DESIGN: We conducted a 3-phase modified Delphi study from 2015 to 2017. SETTING: We recruited a multidisciplinary national expert panel for key informant interviews by telephone and completion of a 2-step online validation process. PARTICIPANTS: The panel consisted of 58 individuals with expertise in local transportation and policy processes, as well as experience in cross-sector collaboration with public health. Participants represented the disciplines of land use planning, transportation/public works, public health, municipal administration, and active transportation advocacy at the state and local levels. MAIN OUTCOME MEASURES: Key informant interviews elicited initial capabilities and tasks. An online survey solicited rankings of impact and feasibility for capabilities and ratings of importance for associated tasks. Feasibility rankings were used to categorize capabilities according to required resources. Results were presented via second online survey for final input. RESULTS: Ten capabilities were categorized according to required resources. Fewest resources were as follows: (1) collaborate with public officials; (2) serve on land use or transportation board; and (3) review plans, policies, and projects. Moderate resources were as follows: (4) outreach to the community; (5) educate policy makers; (6) participate in plan and policy development; and (7) participate in project development and design review. Most resources were as follows: (8) participate in data and assessment activities; (9) fund dedicated staffing; and (10) provide funding support. CONCLUSIONS: These actionable capabilities can guide planning efforts for LHDs of all resource levels.

Driven to Support: Individual- and County-Level Factors Associated With Public Support for Active Transportation Policies.

PURPOSE: To assess predictors of stated support for policies promoting physically active transportation. DESIGN: Cross-sectional. SETTING: US counties selected on county-level physical activity and obesity health status. PARTICIPANTS: Participants completing random-digit dialed telephone survey (n = 906). MEASURES: Survey measures assessed stated support for 5 policies to promote physically active transportation, access to active transportation facilities, and time spent in a car. County-level estimates included household car dependence and funding for bicycle-pedestrian projects. ANALYSIS: Multivariable generalized linear mixed models using binary distribution and logit link, accounting for clustering within county. RESULTS: Respondents supported policies for accommodating bicyclists and pedestrians through street improvements (89%), school active transportation programs (75%), employer-funded active commuting incentives (67%), and allocation of public funding (68%) and tax support (56%) for building and maintaining public transit. Residents spending >2 h/d (vs <0.7 hours) in cars were more likely to support street (odds ratio [OR]: 1.87; confidence interval [CI]: 1.09-3.22) and public transit (OR: 1.85; CI: 1.24-2.77) improvements. Residents in counties investing >$1.6 million in bicycle and pedestrian improvements expressed greater support for funding (OR: 1.71; CI: 1.04-2.83) and tax increases (OR: 1.73; CI: 1.08-2.75) for transit improvements compared to those with lower prior investments (<$276 100). CONCLUSION: Support for policies to enable active transportation is higher where relevant investments in active transportation infrastructure are large (>$1.6 M), public transit is nearby, and respondents drive >2 h/d.

Qualitative Exploration of Cross-Sector Perspectives on the Contributions of Local Health Departments in Land-Use and Transportation Policy.

INTRODUCTION: Transportation and land-use policies can affect the physical activity of populations. Local health departments (LHDs) are encouraged to participate in built-environment policy processes, which are outside their traditional expertise. Cross-sector collaborations are needed, yet stakeholders' perceptions of LHD involvement are not well understood. The objective of this study was to describe the perceived value of LHD participation in transportation and land-use decision making and potential contributions to these processes among stakeholders. METHODS: We analyzed qualitative data from 49 semistructured interviews in 2015. Participants were professionals in 13 US states and 4 disciplines: land-use planning (n = 13), transportation/public works (n = 11), public health (n = 19), and other (municipal administration and bike and pedestrian advocacy [n = 6]). Two analysts conducted directed content analysis. RESULTS: All respondents reported that LHDs offer valuable contributions to transportation and land-use policy processes. They identified 7 contributions (interrater agreement 91%): 1) physical activity and health perspective (n = 44), 2) data analysis and assessment (n = 41), 3) partnerships in the community and across sectors (n = 35), 4) public education (n = 27), 5) knowledge of the public health evidence base and best practices (n = 23), 6) resource support (eg, grant writing, technical assistance) (n = 20), and 7) health equity (n = 8). CONCLUSION: LHDs can leverage their strengths to foster cross-sector collaborations that promote physical activity opportunities in communities. Our results will inform development of sustainable capacity-building models for LHD involvement in built-environment decision making.

Understanding Municipal Officials' Involvement in Transportation Policies Supportive of Walking and Bicycling.

CONTEXT: Local transportation policies can impact the built environment and physical activity. Municipal officials play a critical role in transportation policy and planning decisions, yet little is known about what influences their involvement. OBJECTIVE: To describe municipal officials' involvement in transportation policies that were supportive of walking and bicycling and to examine individual- and job-related predictors of involvement in transportation policies among municipal officials. DESIGN: A cross-sectional survey was administered online from June to July 2012 to municipal officials in 83 urban areas with a population of 50 000 or more residents across 8 states. PARTICIPANTS: A total of 461 municipal officials from public health, planning, transportation, public works, community and economic development, parks and recreation, city management, and municipal legislatures responded to the survey. MAIN OUTCOME MEASURE: Participation in the development, adoption, or implementation of a municipal transportation policy supportive of walking or bicycling. RESULTS: Multivariate logistic regression analyses, conducted in September 2013, revealed that perceived importance of economic development and traffic congestion was positively associated with involvement in a municipal transportation policy (odds ratio [OR] = 1.32, 95% confidence interval [CI] = 1.02-1.70; OR = 1.59, 95% CI = 1.26-2.01, respectively). Higher perceived resident support of local government to address economic development was associated with an increased likelihood of participation in a transportation policy (OR = 1.70, 95% CI = 1.24-2.32). Respondents who perceived lack of collaboration as a barrier were less likely to be involved in a transportation policy (OR = 0.78, 95% CI = 0.63-0.97). Municipal officials who lived in the city or town in which they worked were significantly more likely to be involved in a transportation policy (OR = 1.83, 95% CI = 1.05-3.17). CONCLUSIONS: Involvement in a local transportation policy by a municipal official was associated with greater perceived importance of economic development and traffic congestion in job responsibilities, greater perceived resident support of local government to address economic development, and residence of the municipal official. Lack of collaboration represented a barrier to local transportation policy participation.

Multilevel Analysis of Municipal Officials' Participation in Land Use Policies Supportive of Active Living: City and Individual Factors.

PURPOSE: To investigate individual- and city-level factors associated with municipal officials' participation in a local land use policy that supports active living. DESIGN: Cross-sectional study. SETTING: Eighty-three cities in eight states. SUBJECTS: Four hundred thirteen elected and appointed officials with various job functions including mayors, city councilors, aldermen, selectmen, city or town managers, and heads of departments of planning, community development, public works, transportation, engineering, parks and recreation, neighborhood services, and public health. MEASURES: A Web-based survey assessed perceived importance of physical activity and livability issues to job responsibilities; perceived resident support of local government action to address physical activity and livability issues; and residence. City-level factors obtained from Census data included percentage of commuters by walking, bicycling, and public transit. The dependent variable was self-reported participation in developing, adopting, or implementing a local land use policy supportive of active living. ANALYSIS: Hierarchical (two-level: municipal official-city) logistic regression model, using R. RESULTS: Municipal officials living in the city where they worked were significantly more likely to be involved in a land use policy. Higher perceived importance of livability issues was associated with participation. Perceived importance of physical activity was inversely associated with land use policy involvement. Higher city-level bicycling rates resulted in increased odds of participation in a land use policy. City-level walking rates were inversely associated with land use policy participation. CONCLUSION: Municipal officials who worked in cities with a higher proportion of bicycle commuters, who prioritized livability issues, and who resided in the city where they worked were more likely to engage in land use policies supportive of active living.

Priorities of Municipal Policy Makers in Relation to Physical Activity and the Built Environment: A Latent Class Analysis.

OBJECTIVE: To examine policy makers' public policy priorities related to physical activity and the built environment, identify classes of policy makers based on priorities using latent class analysis, and assess factors associated with class membership. DESIGN: Cross-sectional survey data from municipal officials in 94 cities and towns across 6 US states were analyzed. PARTICIPANTS: Participants (N = 423) were elected or appointed municipal officials spanning public health, planning, transportation/public works, community and economic development, parks and recreation, and city management. MAIN OUTCOME MEASURES: Participants rated the importance of 11 policy areas (public health, physical activity, obesity, economic development, livability, climate change, air quality, natural resource conservation, traffic congestion, traffic safety, and needs of vulnerable populations) in their daily job responsibilities. Latent class analysis was used to determine response patterns and identify distinct classes based on officials' priorities. Logistic regression models assessed participant characteristics associated with class membership. RESULTS: Four classes of officials based on policy priorities emerged: (1) economic development and livability; (2) economic development and traffic concerns; (3) public health; and (4) general (all policy areas rated as highly important). Compared with class 4, officials in classes 1 and 3 were more likely to have a graduate degree, officials in class 2 were less likely to be in a public health job/department, and officials in class 3 were more likely to be in a public health job/department. CONCLUSIONS: Findings can guide public health professionals in framing discussions with policy makers to maximize physical activity potential of public policy initiatives, particularly economic development.

Municipal Officials' Participation in Built Environment Policy Development in the United States.

PURPOSE: This study examined municipal officials' participation in built environment policy initiatives focused on land use design, transportation, and parks and recreation. DESIGN: Web-based cross-sectional survey. SETTING: Eighty-three municipalities with 50,000 or more residents in eight states. SUBJECTS: Four hundred fifty-three elected and appointed municipal officials. MEASURES: Outcomes included self-reported participation in land use design, transportation, and parks and recreation policy to increase physical activity. Independent variables included respondent position; perceptions of importance, barriers, and beliefs regarding physical activity and community design and layout; and physical activity partnership participation. ANALYSIS: Multivariable logistic regression models. RESULTS: Compared to other positions, public health officials had lower participation in land use design (78.3% vs. 29.0%), transportation (78.1% vs. 42.1%), and parks and recreation (67.1% vs. 26.3%) policy. Perceived limited staff was negatively associated with participation in each policy initiative. Perceptions of the extent to which physical activity was considered in community design and physical activity partnership participation were positively associated with participation in each. Perceived lack of collaboration was associated with less land use design and transportation policy participation, and awareness that community design affects physical activity was associated with more participation. Perceived lack of political will was associated with less parks and recreation policy participation. CONCLUSION: Public health officials are underrepresented in built environment policy initiatives. Improving collaborations may improve municipal officials' policy participation.

Support for physical activity policies and perceptions of work and neighborhood environments: variance by BMI and activity status at the county and individual levels.

PURPOSE: To examine support for local policies encouraging physical activity and perceived neighborhood environment characteristics by physical activity and weight status of respondents across U.S. counties. DESIGN: We used a random-digit-dial, computer-assisted telephone interview (CATI) to conduct a cross-sectional telephone questionnaire in selected U.S. counties in 2011. SETTING: Counties with high prevalences of obesity and sedentary behavior (HH; n = 884) and counties with low prevalences of obesity and sedentary behavior (LL; n = 171) were selected nationally. SUBJECTS: Adult respondents from HH (n = 642) and LL (n = 566) counties. MEASURES: Questions were asked of respondents, pertaining to support for physical activity policies in various settings, neighborhood features, time spent in physical activity and sedentary behaviors, self-reported weight and height, and personal demographic information. ANALYSIS: Means and frequencies were calculated; bivariable and multivariable linear and logistic regression models, developed. Models were adjusted for individual characteristics and county HH/LL status. RESULTS: Respondents in LL counties perceived their neighborhood and work environments to be more supportive of healthy behaviors and were more supportive of local physical activity policies than respondents in HH counties (p < .001 for all). Positive neighborhood environment perceptions were related to reduced body mass index, increased physical activity, and decreased sedentary behavior. CONCLUSION: Policy support and neighborhood environments are associated with behaviors. Results can inform targeting policy agendas to facilitate the improvement of environments (community, work, and school) to be more supportive of physical activity.

Policy, systems, and environmental approaches for obesity prevention: a framework to inform local and state action.

The public health literature has not fully explored the complexities of the policy process as they relate to public health practice and obesity prevention. We conducted a review of the literature across the policy science and public health fields, distilled key theories of policy making, and developed a framework to inform policy, systems, and environmental change efforts on obesity prevention. Beginning with a conceptual description, we focus on understanding three domains of the policy process: the problem domain, the policy domain, and the political domain. We identify key activities in the policy process including the following: (a) assessing the social and political environment; (b) engaging, educating and collaborating with key individuals and groups; (c) identifying and framing the problem; (d) utilizing available evidence; (e) identifying policy solutions; and (f) building public support and political will. The article provides policy change resources and case studies to guide and support local and state efforts around obesity prevention.

Municipal officials' perceived barriers to consideration of physical activity in community design decision making.

CONTEXT: Built environment-focused interventions and policies are recommended as sustainable approaches for promoting physical activity. Physical activity has not traditionally been considered in land use and transportation decision making. Effective collaboration with non-public health partners requires knowledge of their perceived barriers to such consideration. OBJECTIVE: This analysis sought to (a) establish prevalence estimates of selected barriers to the consideration of physical activity in community design and layout decisions and (b) describe how barrier reporting by public health officials differs from other municipal officials among a wide range of job functions and departments in a geographically diverse sample. DESIGN: A Web-based survey was conducted among municipal officials in 94 cities and towns with populations of at least 50 000 residents in 8 states. PARTICIPANTS: A total of 453 municipal officials from public health, planning, transportation/public works, community and economic development, parks and recreation, city management, and municipal legislatures in 83 cities and towns responded to the survey. MAIN OUTCOME MEASURES: Five barriers to consideration of physical activity in community design and layout were assessed. RESULTS: The most common barriers included lack of political will (23.5%), limited staff (20.4%), and lack of collaboration across municipal departments (16.2%). Fewer participants reported opposition from the business community or residents as barriers. Public health department personnel were more likely to report the barriers of limited staff and lack of collaboration across municipal departments than other professionals. They were also more likely to report lack of political will than city managers or mayors and municipal legislators. CONCLUSIONS: Barriers to increasing consideration of physical activity in decision making about community design and layout are encouragingly low. Implications for public health practice include the need to strategically increase political will despite public health staffing constraints and perceived lack of collaboration with relevant departments such as planning and public works/transportation.

Active living collaboratives in the United States: understanding characteristics, activities, and achievement of environmental and policy change.

INTRODUCTION: Changing the built environment to promote active lifestyles requires collaboration among diverse sectors. Multisectoral collaborative groups in the United States promote active lifestyles through environmental and policy changes. The objective of this study was to examine the characteristics of these collaborative groups and the extent to which they have achieved change. METHODS: We identified, recruited, and interviewed the coordinators of active living collaborative groups in the United States. We used descriptive statistics to characterize groups by composition, stakeholder engagement, and the extent of environmental and policy change in 8 strategic areas. RESULTS: Fifty-nine groups from 22 states participated in the study. Most groups had a diverse set of partners and used a range of activities to advance their agendas. Most groups achieved some form of environmental or policy change. On average, groups reported working on 5 strategy areas; parks and recreation (86%) and Safe Routes to School (85%) were named most frequently. More than half of groups reported their environmental initiatives as either in progress or completed. Groups reported the most success in changing policy for public plazas, street improvements, streetscaping, and parks, open space, and recreation. Complete Streets policy and zoning ordinances were the most frequently cited policy types. Engaging in media activities and the policy-making process in addition to engaging stakeholders appear to influence success in achieving change. CONCLUSION: Although many groups successfully worked on parks and recreation improvements, opportunities remain in other areas, including transit and infill and redevelopment. Additional time and resources may be critical to realizing these types of changes.

Predictors of smoking cessation in pregnancy and maintenance postpartum in low-income women.

OBJECTIVE: To describe factors associated with smoking status of low-income women during pregnancy and postpartum. METHODS: Data from a randomized clinical trial were used to conduct separate analyses on 327 women who smoked at baseline (time at enrollment) and for whom smoking status was available at delivery, and on 109 women who reported not smoking at delivery (quit spontaneously or after study enrollment) and for whom smoking status was available at 6-months postpartum. Salivary cotinine was used to assess the accuracy of self-reported smoking status for the sample as a whole. Data were collected between May 1997 and November 2000. RESULTS: 18% of the 327 baseline smokers stopped smoking before delivery. Cessation was less likely in older women, those reporting Medicaid coverage (vs. commercial or no insurance), who were at a later week of pregnancy at baseline, were more addicted, had a husband/partner who smoked, and did not receive the study intervention. 37% of the 109 women who reported not smoking at delivery maintained abstinence at 6-months postpartum. Factors associated with abstinence were later week of pregnancy at baseline and quitting spontaneously with pregnancy, while women who lived with a smoker were less likely to report abstinence. Spontaneous quitters were less likely to relapse by 6 months postpartum than women who quit smoking later in pregnancy. CONCLUSIONS: Partner participation in smoking cessation programs for pregnant and postpartum women merits exploration. Lower relapse rates among spontaneous quitters indicate a need to foster an environment that encourages quitting at pregnancy.

Recommendations for care related to follow-up of abnormal cancer screening tests: accuracy of patient report.

When using patient self-report of processes of care as part of measuring quality performance, validity and reliability are important considerations. In this study, the congruence of patient report of recommendations of screening follow-up care was compared with record audit data. Survey data were collected from a random sample of patients with abnormal breast (n = 230) or cervical (n = 219) cancer screening tests from four health centers. With patient consent, record audits were conducted to validate self-report. Measures of congruence for recommendations for follow-up were calculated along with sensitivity and specificity for procedure-specific recommendations. Overall congruence was higher in the mammography sample (81%) as compared to the Pap sample (61%). Predictors of overall congruence for the abnormal Pap test sample included health plan, self-reported health status, and test result. There were no significant predictors of congruence for the abnormal mammogram test sample from the potential variables collected. Raw agreement rates support using patient self-report in assessing abnormal test follow-up recommendations.

Coronary heart disease multiple risk factor reduction. Providers' perspectives.

BACKGROUND: Although primary care physicians understand the importance of preventive services for patients with multiple risk factors (MRF) for coronary heart disease, physician intervention is limited. This study investigated (1) physicians' views of challenges faced in managing patients with MRF; (2) the counseling and management methods they utilize; and (3) possible strategies to enhance MRF intervention in the primary care setting. METHODS: Two focus groups were conducted with primary care physicians from varying settings to gain insight into these issues noted above. Each group was co-facilitated by a physician and a behavioral scientist using a previously developed semistructured interview guide. The group discussions were tape recorded and subsequently transcribed. Transcripts were analyzed using the constant comparative method for analysis. RESULTS: Physicians are challenged by knowledge limitations (contribution of individual risk factors to overall risk); limited support (guidelines, materials, and staff); and logistic difficulties (organizational issues, time limitations). Their approach to MRF management tends to be highly individualized with an initial preference for lifestyle change interventions rather than prescription of medications with some qualifying circumstances. Physicians favored a serial rather than a parallel approach to MRF intervention, starting with behaviors that the patient perceives as a priority. Proposed solutions to current challenges emphasize physician education and the development of innovative approaches that include physician assistance and a team approach. CONCLUSIONS: Physicians are aware of and sensitive to the complexity of MRF management for their patients and themselves. However, future MRF interventions will require nonphysician staff involvement and increased systems support.