Adaptation of an Evidence-Based Diabetes Management Intervention for Delivery in Community Settings: Findings From a Pilot Randomized Effectiveness Trial.

Objective: To adapt an evidence-based intervention targeting diabetes management in adolescents with poorly controlled type 1 diabetes for use in a community setting by community health workers (CHWs) and to conduct pilot testing of the new intervention, REACH for Control (RFC). The study was conducted as a collaboration between university researchers and a federally qualified health center. Methods In a pilot effectiveness trial, feasibility and acceptability of RFC were evaluated based on participant enrollment, treatment dose, and consumer satisfaction. RFC effects on adolescent adherence, health outcomes, and quality of life were also assessed. The trial used a parallel group design. Families were randomized to 6 months of RFC plus standard medical care (n = 26) or standard care (SC) only (n = 24). Data were collected at baseline and 7-month posttest. A mixed-methods approach was used to analyze data. Results: Qualitative analyses suggested that caregivers viewed RFC and delivery of a home-based intervention by CHWs positively. Furthermore, adolescents who received RFC had statistically significant (p = .05) and clinically meaningful improvements in hemoglobin A1c (HbA1c) (0.7%) and reported significant improvements in quality of life from baseline to follow-up (p = .001). No significant changes were found for adolescents in standard medical care. However, while dose of primary intervention session delivered was acceptable, dose of follow-up sessions used for skills practice was low. Conclusions: Results provide preliminary support for RFC's acceptability and effectiveness to improve health status and quality of life when used in community settings serving high-risk, low-income families. Additional testing in a full-scale effectiveness trial appears warranted.

A Multi-Site Study of Social Cognitive Factors Related to Adherence Among Youth Living With HIV in the New Era of Antiretroviral Medication.

Objective: The goal of the current study was to determine how a set of social cognitive factors predict antiretroviral therapy (ART) medication adherence in youth living with HIV in an era of newer highly active ART medications using a conceptual model. Methods: Behaviorally infected youth living with HIV ages 13-24 (N = 822) from 14 sites within the Adolescent Medicine Trials Unit (AMTU) were included in the study. Structural equation modeling was used to explore predictors of ART medication adherence. Results: Results found that motivational readiness for ART was related to higher ART medication adherence, which was associated with lower viral load. Higher social support and higher self-efficacy had an indirect relationship with higher adherence through increased motivational readiness. Fewer psychological symptoms were associated with higher social support and higher self-efficacy. Lower substance use was directly associated with lower adherence. Conclusions: The results provide insight into factors that may be related to adherence in youth living with HIV. Findings suggest focusing on motivational readiness to increase adherence. Improving the patients' ART self-efficacy and strengthening their social support networks during treatment can increase motivational readiness for ART treatment. Furthermore, programs maybe more effective with the inclusion of risk reduction components especially those related to substance use.

Efficacy of mindfulness-based stress reduction in emerging adults with poorly controlled, type 1 diabetes: A pilot randomized controlled trial.

BACKGROUND/OBJECTIVE: The negative effects of stress on persons with type 1 diabetes (T1D) are well-established, but effective interventions to reduce stress among emerging adults with T1D are limited. The study objective was to conduct a pilot randomized controlled trial (RCT) to obtain preliminary data on the efficacy of mindfulness-based stress reduction (MBSR) to reduce stress and improve diabetes health outcomes in a population of high-risk, urban emerging adults with poorly controlled diabetes. METHODS: Forty-eight participants aged 16 to 20 years of age with T1D (mean duration = 8 years) were randomly assigned to one of three conditions: MSBR, cognitive-behavioral stress management (CBSM), or a diabetes support group. Data were collected at baseline, end of treatment, and 3 months after treatment completion. Measures of self-reported stress and depressive symptoms, diabetes management, and glycemic control were obtained. RESULTS: MBSR was found to reduce self-reported stress at end of treatment (P = 0.03, d = -0.49) and 3-month follow-up (P = 0.01, d = -0.67), but no effects on diabetes management or glycemic control were found. Diabetes support group participants had improved glycemic control at the end of treatment (P = 0.01, d = -0.62) as well as reduced depressive symptoms at 3-month follow-up (P = 0.01, d = -0.71). CONCLUSIONS: Results provide preliminary support for the efficacy of MBSR to improve psychosocial adjustment in emerging adults with poorly controlled T1D but require replication in adequately powered studies. Findings also support the value of peer support in improving health outcomes in this age group.

Calendaring and alarms can improve naturalistic time-based prospective memory for youth infected with HIV.

Individuals with HIV disease often evidence deficits in prospective memory (PM), which interfere with daily functioning and increase the risk of suboptimal health behaviours. This study examined the benefits of simple encoding and cueing supports on naturalistic time-based PM in 47 HIV-positive young adults. All participants completed a naturalistic time-based PM task in which they were instructed to text the examiner once per day for seven days at a specified time. Participants were randomised into (1) a Calendaring condition in which they created a calendar event in their mobile telephone for the specified texting time; (2) an Alarm condition in which they programmed an alarm into their mobile telephone for the specified texting time; (3) a Combined calendaring and alarm condition; and (4) a Control condition. Participants in the Combined condition demonstrated significantly better naturalistic PM performance than participants in the Control and Calendaring conditions. Findings indicate that HIV-positive young people may benefit from a combined calendaring and alarm supportive strategy for successful execution of future intentions in daily life.

Brief Computer-Delivered Intervention to Increase Parental Monitoring in Families of African American Adolescents with Type 1 Diabetes: A Randomized Controlled Trial.

BACKGROUND: African American adolescents with type 1 diabetes (T1D) are at elevated risk for poor diabetes management and metabolic control. Parental supervision and monitoring of adolescent diabetes management have been shown to promote better diabetes management among adolescents, but parents typically decrease their oversight during the transition to independent diabetes care. INTRODUCTION: The purpose of the study was to conduct a randomized clinical trial to test the feasibility and efficacy of a three-session, computer-delivered motivational intervention (The 3Ms) to promote increased parental monitoring among primary caregivers of young African American adolescents with T1D. The intervention was brief and optimized for delivery during routine diabetes clinic visits. MATERIALS AND METHODS: Sixty-seven adolescents with T1D aged 11-14 and their primary caregiver were randomly assigned to one of three arms: adolescent and parent motivational intervention (Arm 1), adolescent control and parent motivational intervention (Arm 2), or adolescent and parent control (Arm 3). Intervention effects were assessed 1 month after intervention completion. RESULTS: Parents in Arm 1 and Arm 2 had significant increases in knowledge of the importance of monitoring adolescents' diabetes care. Parents in Arm 2 also had trend to significant increases in direct observation and monitoring of adolescent diabetes care, and adolescents in Arm 2 had significant improvements in glycemic control. DISCUSSION AND CONCLUSIONS: Findings from the present study provide preliminary support for the efficacy of a brief, computer-delivered parenting intervention for improving family management practices and adolescent health outcomes among African American adolescents with T1D and their caregivers.

Visualisation of future task performance improves naturalistic prospective memory for some younger adults living with HIV disease.

Human immunodeficiency virus (HIV) disease is commonly associated with deficits in prospective memory (PM), which increase the risk of suboptimal health behaviours, like medication non-adherence. This study examined the potential benefits of a brief future visualisation exercise during the encoding stage of a naturalistic PM task in 60 young adults (aged 19-24 years) with HIV disease. Participants were administered a brief clinical neuropsychological assessment, which included a standardised performance-based measure of time- and event-based PM. All participants were also given a naturalistic PM task in which they were asked to complete a mock medication management task when the examiner showed them the Grooved Pegboard Test during their neuropsychological evaluation. Participants were randomised into: (1) a visualisation condition in which they spent 30 sec imagining successfully completing the naturalistic PM task; or (2) a control condition in which they repeated the task instructions. Logistic regression analyses revealed significant interactions between clinical neurocognitive functions and visualisation. HIV positive (HIV+) participants with intact retrospective learning and/or low time-based PM demonstrated observable gains from the visualisation technique, while HIV+ participants with impaired learning and/or intact time-based PM did not evidence gains. Findings indicate that individual differences in neurocognitive ability moderate the response to visualisation in HIV+ young adults. The extent to which such cognitive supports improve health-related PM outcomes (e.g., medication adherence) remains to be determined.

Effects of socio-demographic factors on parental monitoring, and regimen adherence among adolescents with type 1 diabetes: A moderation analysis.

Parental monitoring of adolescent diabetes care is an important predictor of adolescent regimen adherence. To date, no studies have investigated whether socio-demographic factors are associated with low levels of parental monitoring or differences in parental monitoring styles, and their moderating effects in families of adolescents with type 1 diabetes. The purpose of this cross-sectional study was to determine whether youth and family socio-demographic factors moderated the relationship between monitoring and youth regimen adherence (i.e., mean frequency of blood glucose testing [BGT]). Data were collected from 267 adolescents with type 1 diabetes and their parents. Hierarchical multiple regression analyses were employed. Socio-demographic factors accounted for 17.1% of the variance in adherence. After parental monitoring scales were entered, R2 in all eight equations increased and R2 change score in six of eight equations were significant. All models were significant after the interaction terms were entered. In the adolescent report models, parent age and family structure were both independently associated with adherence and also moderated the association between adolescent-report parental monitoring and adherence to diabetes care, in particular, adolescent report of parental direct observation/presence during diabetes care. In the parent report models, income was moderated the association between parent-report youth disclosure and adherence. Research should focus on identifying additional modifiable factors that place families at risk for low levels of parental monitoring of diabetes care. Future clinical research is needed to help identify risk factors for low levels of parental monitoring and develop interventions to promote optimal parenting skills that can support youth diabetes care.

Mediators of Treatment Effects in a Randomized Clinical Trial of Multisystemic Therapy-Health Care in Adolescents With Poorly Controlled Asthma: Disease Knowledge and Device Use Skills.

OBJECTIVE: Determine whether Multisystemic Therapy-Health Care (MST-HC) improved asthma knowledge and controller device use skills among African-American youth with poorly controlled asthma and whether any improvements mediated changes in illness management. METHODS: A randomized controlled trial was conducted with 170 adolescents with moderate to severe asthma. Families were randomized to MST-HC or attention control. Data were collected at baseline and 6 and 12 months after intervention completion. RESULTS: In linear mixed models, adolescents in the MST-HC group had increases in asthma knowledge; asthma knowledge was unchanged for attention control. Controller device use skills increased for adolescents in the MST-HC group, while skills declined for attention control. Both knowledge and skills mediated the relationship between intervention condition and changes in illness management. CONCLUSIONS: Tailored, home-based interventions that include knowledge and skills building components are one means by which illness management in African-American youth with poorly controlled asthma can be improved.

Sequential Multiple Assignment Randomized Trial (SMART) to Construct Weight Loss Interventions for African American Adolescents.

The purpose of this study was to develop an adaptive behavioral treatment for African American adolescents with obesity. In a sequential multiple assignment randomized trial, 181 youth ages 12-16 years with primary obesity and their caregiver were first randomized to 3 months of home-based versus office-based delivery of motivational interviewing plus skills building. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based skills or contingency management. Primary outcome was percent overweight and hypothesized moderators were adolescent executive functioning and depression. There were no significant differences in primary outcome between home-based or office-based delivery or between continued home-based skills or contingency management for nonresponders to first-phase treatment. However, families receiving home-based treatment initially attended significantly more sessions in both phases of the trial, and families receiving contingency management attended more sessions in the second phase. Overall, participants demonstrated decreases in percent overweight over the course of the trial (3%), and adolescent executive functioning moderated this effect such that those with higher functioning lost more weight. More potent behavioral treatments to address the obesity epidemic are necessary, targeting new areas such as executive functioning. Delivering treatment in the home with contingency management may increase session attendance for this population.

Recruitment strategies and the retention of obese urban racial/ethnic minority adolescents in clinical trials: the FIT families project, Michigan, 2010-2014.

INTRODUCTION: The successful recruitment and retention of participants is integral to the translation of research findings. We examined the recruitment and retention rates of racial/ethnic minority adolescents at a center involved in the National Institutes of Health Obesity Research for Behavioral Intervention Trials (ORBIT) initiative by the 3 recruitment strategies used: clinic, informatics, and community. METHODS: During the 9-month study, 186 family dyads, each composed of an obese African American adolescent and a caregiver, enrolled in a 6-month weight-loss intervention, a sequential multiple assignment randomized trial. We compared recruitment and retention rates by recruitment strategy and examined whether recruitment strategy was related to dyad baseline characteristics. RESULTS: Of the 186 enrolled families, 110 (59.1%) were recruited through clinics, 53 (28.5%) through informatics, and 23 (12.4%) through community. Of those recruited through community, 40.4% enrolled in the study, compared with 32.7% through clinics and 8.2% through informatics. Active refusal rate was 3%. Of the 1,036 families identified for the study, 402 passively refused to participate: 290 (45.1%) identified through informatics, 17 (29.8%) through community, and 95 (28.3%) through clinics. Recruitment strategy was not related to the age of the adolescent, adolescent comorbidities, body mass index of the adolescent or caregiver, income or education of the caregiver, or retention rates at 3 months, 7 months, or 9 months. Study retention rate was 87.8%. CONCLUSION: Using multiple recruitment strategies is beneficial when working with racial/ethnic minority adolescents, and each strategy can yield good retention. Research affiliated with health care systems would benefit from the continued specification, refinement, and dissemination of these strategies.

From ideas to efficacy: The ORBIT model for developing behavioral treatments for chronic diseases.

OBJECTIVE: Given the critical role of behavior in preventing and treating chronic diseases, it is important to accelerate the development of behavioral treatments that can improve chronic disease prevention and outcomes. Findings from basic behavioral and social sciences research hold great promise for addressing behaviorally based clinical health problems, yet there is currently no established pathway for translating fundamental behavioral science discoveries into health-related treatments ready for Phase III efficacy testing. This article provides a systematic framework for developing behavioral treatments for preventing and treating chronic diseases. METHOD: The Obesity-Related Behavioral Intervention Trials (ORBIT) model for behavioral treatment development features a flexible and progressive process, prespecified clinically significant milestones for forward movement, and return to earlier stages for refinement and optimization. RESULTS: This article presents the background and rationale for the ORBIT model, a summary of key questions for each phase, a selection of study designs and methodologies well-suited to answering these questions, and prespecified milestones for forward or backward movement across phases. CONCLUSIONS: The ORBIT model provides a progressive, clinically relevant approach to increasing the number of evidence-based behavioral treatments available to prevent and treat chronic diseases. (PsycINFO Database Record

Interpretable Probabilistic Latent Variable Models for Automatic Annotation of Clinical Text.

We propose Latent Class Allocation (LCA) and Discriminative Labeled Latent Dirichlet Allocation (DL-LDA), two novel interpretable probabilistic latent variable models for automatic annotation of clinical text. Both models separate the terms that are highly characteristic of textual fragments annotated with a given set of labels from other non-discriminative terms, but rely on generative processes with different structure of latent variables. LCA directly learns class-specific multinomials, while DL-LDA breaks them down into topics (clusters of semantically related words). Extensive experimental evaluation indicates that the proposed models outperform Naïve Bayes, a standard probabilistic classifier, and Labeled LDA, a state-of-the-art topic model for labeled corpora, on the task of automatic annotation of transcripts of motivational interviews, while the output of the proposed models can be easily interpreted by clinical practitioners.

Naturalistically observed conflict and youth asthma symptoms.

OBJECTIVE: To investigate the links between naturalistically observed conflict, self-reported caregiver-youth conflict, and youth asthma symptoms. METHOD: Fifty-four youth with asthma (age range: 10-17 years) wore the Electronically Activated Recorder (EAR) for a 4-day period to assess interpersonal conflict and caregiver-youth conflict as they occur in daily life. Conflict also was assessed with baseline self-report questionnaires and daily diaries completed by youth participants and their caregivers. Asthma symptoms were assessed using daily diaries, baseline self-reports, and wheezing, as coded from the EAR. RESULTS: EAR-observed measures of conflict were strongly associated with self-reported asthma symptoms (both baseline and daily diaries) and wheezing coded from the EAR. Further, when entered together in regression analyses, youth daily reports of negative caregiver-youth interactions and EAR-observed conflict uniquely predicted asthma symptoms; only EAR-observed conflict was associated with EAR-observed wheezing. CONCLUSION: These findings demonstrate the potential impact of daily conflict on youth asthma symptoms and the importance of assessing conflict as it occurs in everyday life. More broadly, they point to the importance of formulating a clear picture of family interactions outside of the lab, which is essential for understanding how family relationships "get under the skin" to affect youth health.

Motivational interviewing targeting risky sex in HIV-positive young Thai men who have sex with men.

Motivational interviewing (MI) has been shown to reduce sexual risks among HIV-positive men who have sex with men (HMSM) in the US. We conducted a randomized trial of Healthy Choices, a 4-session MI intervention, targeting sexual risks among 110 HIV-positive youth ages 16-25 years in Thailand. Risk assessments were conducted at baseline, 1 month, and 6 months post-intervention. This report presents the analysis of 74 HMSM in the study. There were 37 HMSM in the Intervention group and 37 in the control group. The proportions of participants having anal sex and having sex with either HIV-uninfected or unknown partners in past 30 days were significantly lower in Intervention group than in Control group at 6 months post-intervention (38 vs. 65 %, p = .04; and 27 vs. 62 %, p < .01, respectively). There were no significant differences in general mental health scores and HIV stigma scores between the two groups at any study visit. Thirty-five (95 %) HMSM in the Intervention group vs. 31 (84 %) in control group attended ≥ 3 sessions. Loss to follow-up was 8 and 30 %, respectively (p = .04). Healthy Choices for young Thai HMSM was associated with sexual risk reduction. Improvements in mental health were noted in Intervention group. Healthy Choices is a promising behavioral intervention and should be further developed to serve the needs of young HMSM in resource-limited countries.

Correlation between use of antiretroviral adherence devices by HIV-infected youth and plasma HIV RNA and self-reported adherence.

Our objective was to investigate antiretroviral adherence device use by HIV-infected youth and assess associations of device use with viral suppression and self-reported adherence. This cross-sectional, multisite, clinic-based study included data from 1,317 HIV-infected individuals 12-24 years of age that were prescribed antiretroviral therapy. Mean adherence in the past 7 days was 86.1 % and 50.5 % had an undetectable HIV RNA. Pillbox was the most commonly endorsed device. No specific device was independently associated with higher odds of 100 % adherence. Paradoxically, having an undetectable HIV RNA was inversely associated with use of adherence devices (OR 0.80; p = 0.04); however, among those with <100 % adherence, higher adherence was associated with use of one or more adherence devices (coefficient = 7.32; p = 0.003). Our data suggest that adolescents who experienced virologic failure often used adherence devices which may not have been sufficiently effective in optimizing adherence. Therefore, other tailored adherence-enhancing methods need to be considered to maximize virologic suppression and decrease drug resistance and HIV transmission.

Effects of family treatment on parenting beliefs among caregivers of youth with poorly controlled asthma.

OBJECTIVE: Caregiver involvement is critical in ensuring optimal adolescent asthma management. The study investigated whether multisystemic therapy (MST), an intensive home-based family therapy, was superior to family support for changing beliefs regarding asthma-related positive parenting among caregivers of African-American youth with poorly controlled asthma. The relationship between parenting beliefs and asthma management at the conclusion of the intervention was also assessed. METHODS: A randomized controlled trial was conducted with 167 adolescents with moderate-to-severe, persistent, poorly controlled asthma and their primary caregivers. Families were randomly assigned to MST or family support (FS), a home-based family support condition. Data were collected at baseline and 7-month posttest. Changes in caregiver ratings of importance and confidence for engaging in asthma-related positive parenting were assessed through questionnaire. Illness management was assessed by the Family Asthma Management System Scale. RESULTS: Participation in MST was associated with more change in caregiver beliefs as compared with FS for both importance (t = 2.39, p = .02) and confidence (t = 2.04, p = .04). Caregiver beliefs were also significantly related to youth controller medication adherence at the conclusion of treatment (importance: r = .21, p = .01; confidence: r = .23, p = .004). CONCLUSION: Results support the effectiveness of MST for increasing parental beliefs in the value of asthma-related positive parenting behaviors and parental self-efficacy for these behaviors among families of minority adolescents with poorly controlled asthma.

Allowing brief delays in responding improves event-based prospective memory for young adults living with HIV disease.

Event-based prospective memory (PM) tasks require individuals to remember to perform an action when they encounter a specific cue in the environment, and they have clear relevance for daily functioning for individuals with HIV. In many everyday tasks, not only must the individual maintain the intent to perform the PM task, but the PM task response also competes with the alternative and more habitual task response. The current study examined whether event-based PM can be improved by slowing down the pace of the task environment. Fifty-seven young adults living with HIV performed an ongoing lexical decision task while simultaneously performing a PM task of monitoring for a specific word (which was focal to the ongoing task of making lexical decisions) or syllable contained in a word (which was nonfocal). Participants were instructed to refrain from making task responses until after a tone was presented, which occurred at varying onsets (0-1600 ms) after each stimulus appeared. Improvements in focal and nonfocal PM accuracy were observed with response delays of 600 ms. Furthermore, the difference in PM accuracy between the low-demand focal PM task and the resource-demanding nonfocal PM task was reduced by half across increasingly longer delays, falling from 31% at 0-ms delay to only 14% at 1600-ms delay. The degree of ongoing task response slowing for the PM conditions, relative to a control condition that did not have a PM task and made lexical decisions only, also decreased with increased delay. Overall, the evidence indicates that delaying the task responses of younger HIV-infected adults increased the probability that the PM relevant features of task stimuli were adequately assessed prior to the ongoing task response, and by implication that younger HIV infected adults can more adequately achieve PM goals when the pace of the task environment is slowed down.

Task importance affects event-based prospective memory performance in adults with HIV-associated neurocognitive disorders and HIV-infected young adults with problematic substance use.

Two experiments were conducted to examine the effects of task importance on event-based prospective memory (PM) in separate samples of adults with HIV-associated neurocognitive disorders (HAND) and HIV-infected young adults with substance use disorders (SUD). All participants completed three conditions of an ongoing lexical decision task: (1) without PM task requirements; (2) with PM task requirements that emphasized the importance of the ongoing task; and (3) with PM task requirements that emphasized the importance of the PM task. In both experiments, all HIV+ groups showed the expected increase in response costs to the ongoing task when the PM task's importance was emphasized. In Experiment 1, individuals with HAND showed significantly lower PM accuracy as compared to HIV+ subjects without HAND when the importance of the ongoing task was emphasized, but improved significantly and no longer differed from HIV+ subjects without HAND when the PM task was emphasized. A similar pattern of findings emerged in Experiment 2, whereby HIV+ young adults with SUD (especially cannabis) showed significant improvements in PM accuracy when the PM task was emphasized. Findings suggest that both HAND and SUD may increase the amount of cognitive attentional resources that need to be allocated to support PM performance in persons living with HIV infection.