A religiously-tailored, multilevel intervention in African American churches to increase HIV testing: Rationale and design of the Taking It to the Pews cluster randomized trial.

HIV continues to disproportionately impact African American (AA) communities. Due to delayed HIV diagnosis, AAs tend to enter HIV treatment at advanced stages. There is great need for increased access to regular HIV testing and linkage to care services for AAs. AA faith institutions are highly influential and have potential to increase the reach of HIV testing in AA communities. However, well-controlled full-scale trials have not been conducted in the AA church context. We describe the rationale and design of a 2-arm cluster randomized trial to test a religiously-tailored HIV testing intervention (Taking It to the Pews [TIPS]) against a standard information arm on HIV testing rates among AA church members and community members they serve. Using a community-engaged approach, TIPS intervention components are delivered by trained church leaders via existing multilevel church outlets using religiously-tailored HIV Tool Kit materials and activities (e.g., sermons, responsive readings, video/print testimonials, HIV educational games, text messages) to encourage testing. Church-based HIV testing events and linkage to care services are conducted by health agency partners. Control churches receive standard, non-tailored HIV information via multilevel church outlets. Secondarily, HIV risk/protective behaviors and process measures on feasibility, fidelity, and dose/exposure are assessed. This novel study is the first to fully test an HIV testing intervention in AA churches - a setting with great reach and influence in AA communities. It could provide a faith-community engagement model for delivering scalable, wide-reaching HIV prevention interventions by supporting AA faith leaders with religiously-appropriate HIV toolkits and health agency partners.

Study design and baseline description of the BMI2 trial: reducing paediatric obesity in primary care practices.

OBJECTIVES: This study will test the efficacy of motivational interviewing (MI) conducted by primary care providers and dieticians among children ages 2-8 years old with a body mass index (BMI) ≥ 85th and ≤ 97th percentile. METHODS: Forty-two practices from the American Academy of Pediatrics, Pediatric Research in Office Settings Network were assigned to one of three groups. Group 1 (usual care) measures BMI percentile at baseline, and at 1- and 2-year follow-ups and receives standard health education materials. Group 2 providers deliver three proactive MI counselling sessions with a parent of the index child in Year 1 and one additional 'booster' visit in Year 2. Group 3 adds six MI counselling sessions from a trained dietician. The primary outcome is the child's BMI percentile at 2-year follow-up. Secondary outcomes include parent report of the child's screen time, physical activity, intake of fruits and vegetables, and sugar-sweetened beverages. RESULTS: We enrolled 633 eligible children whose mean BMI percentile was 92.0 and mean age of 5.1. The cohort was 57% female. Almost 70% of parents reported a household income of ≥ $40,000 per year, and 39% had at least a college education. The cohort was 63% white, 23% Hispanic, 7% black and 7% Asian. Parent self-reported confidence that their child will achieve a healthy weight was on average an 8 (out of 10). CONCLUSION: To date, several aspects of the study can inform similar efforts including our ability to use volunteer clinicians to recruit participants and their willingness to dedicate their time, without pay, to receive training in MI.

Factors associated with nonresponse to a computer-tailored asthma management program for urban adolescents with asthma.

BACKGROUND: The ability to identify potentially resistant participants early in the course of an intervention could inform development of strategies for behavior change and improve program effectiveness. OBJECTIVE: The objective of this analysis was to identify factors related to nonresponse (i.e., lack of behavior change) to an asthma management intervention for urban teenagers. The intervention targeted several behaviors, including medication adherence, having a rescue inhaler nearby, and smoking. METHODS: A discriminate analysis was conducted using data from a randomized trial of the intervention. Included in this analysis are participants who reported a physician diagnosis of asthma, completed a baseline questionnaire, were randomized to the treatment group, completed >or=2 of 4 educational sessions, and completed >or=2 of 3 follow-up questionnaires. Ninety students met criteria for inclusion in this subgroup analysis. RESULTS: In logistic regression models for medication adherence, nonresponse was related to low baseline asthma self-regulation, odds ratio = 3.6 (95% confidence interval = 1.3-9.5). In models for having an inhaler nearby, nonresponse was related to low baseline self-regulation and to rebelliousness, OR = 4.7 (1.6-13.2) and 5.6 (1.7-18.0), respectively. Nonresponse to smoking messages was related to rebelliousness, low emotional support, and low religiosity, ORs = 7.6 (1.8-32.3), 9.5 (1.4-63.5), and 6.6 (1.5-29.8) respectively. CONCLUSIONS: Certain variables had the ability to discriminate the likelihood of response from that of nonresponse to an asthma program for urban, African American adolescents with asthma. These variables can be used to identify resistant subgroups early in the intervention, allowing the application of specialized strategies through tailoring. These types of analyses can inform behavioral interventions.

Do-not-resuscitate orders and predictive models after intracerebral hemorrhage.

OBJECTIVE: To quantify the accuracy of commonly used intracerebral hemorrhage (ICH) predictive models in ICH patients with and without early do-not-resuscitate orders (DNR). METHODS: Spontaneous ICH cases (n = 487) from the Brain Attack Surveillance in Corpus Christi study (2000-2003) and the University of California, San Francisco (June 2001-May 2004) were included. Three models (the ICH Score, the Cincinnati model, and the ICH grading scale [ICH-GS]) were compared to observed 30-day mortality with a chi(2) goodness-of-fit test first overall and then stratified by early DNR orders. RESULTS: Median age was 71 years, 49% were female, median Glasgow Coma Scale score was 12, median ICH volume was 13 cm(3), and 35% had early DNR orders. Overall observed 30-day mortality was 42.7% (95% confidence interval [CI] 38.3-47.1), with the average model-predicted 30-day mortality for the ICH Score, Cincinnati model, and ICH-GS at 39.9% (p = 0.005), 40.4% (p = 0.007), and 53.9% (p < 0.001). However, for patients with early DNR orders, the observed 30-day mortality was 83.5% (95% CI 78.0-89.1), with the models predicting mortality of 64.8% (p < 0.001), 57.2% (p < 0.001), and 77.8% (p = 0.02). For patients without early DNR orders, the observed 30-day mortality was 20.8% (95% CI 16.5-25.7), with the models predicting mortality of 26.6% (p = 0.05), 31.4% (p < 0.001), and 41.1% (p < 0.001). CONCLUSIONS: ICH prognostic model performance is substantially impacted when stratifying by early DNR status, possibly giving a false sense of model accuracy when DNR status is not considered. Clinicians should be cautious when applying these predictive models to individual patients.

Interviewer effects in public health surveys.

Interviewer effects can have a substantial impact on survey data and may be particularly operant in public health surveys, where respondents are likely to be queried about racial attitudes, sensitive behaviors and other topics prone to socially desirable responding. This paper defines interviewer effects, argues for the importance of measuring and controlling for interviewer effects in health surveys, provides advice about how to interpret research on interviewer effects and summarizes research to date on race, ethnicity and gender effects. Interviewer effects appear to be most likely to occur when survey items query attitudes about sociodemographic characteristics or respondents' engagement in sensitive behaviors such as substance use. However, there is surprisingly little evidence to indicate whether sociodemographic interviewer-respondent matching improves survey response rates or data validity, and the use of a matched design introduces possible measurement bias across studies. Additional research is needed to elucidate many issues, including the influence of interviewers' sociodemographic characteristics on health-related topics, the role of within-group interviewer variability on survey data and the simultaneous impact of multiple interviewer characteristics. The findings of such research would provide much-needed guidance to public health professionals on whether or not to match interviewers and respondents on key sociodemographic characteristics.

Underweight, overweight and obesity among South African adolescents: results of the 2002 National Youth Risk Behaviour Survey.

OBJECTIVE: The present paper reports the prevalence of underweight, overweight and obesity by gender, ethnicity and grade, among participants in a 2002 national survey among South African school-going youth that included height and weight measurements. DESIGN: A stratified two-stage sample was used. Nationally representative rates of underweight, overweight and obesity were calculated using weighted survey data and compared using chi2 analysis. SETTING: In all, 9224 grade 8 to grade 11 students, present at school in selected classes within selected South African government-funded schools in all nine provinces, participated in this study. Most of the students were between 13 and 19 years of age. RESULTS: Higher rates of underweight were observed for males than females as well as for black and 'coloured' than white students. Within each gender group, black and 'coloured' students had significantly higher rates of underweight than their white counterparts. Higher percentages of females than males were overweight and obese, overall and among black students. Furthermore, white male students had significantly higher rates of overweight than their black and 'coloured' counterparts. Among females, black and white students had significantly higher rates than 'coloured' students. Students in higher grades showed significantly lower rates of underweight and higher rates of overweight. DISCUSSION: These data confirm that South Africa, a developing nation in socio-economic transition, is experiencing both undernutrition and overnutrition. However, these problems are disproportionately distributed by gender, socio-economics and ethnicity. Continued surveillance of nutritional status may be one important component of a national strategy to prevent and control malnutrition.

Using motivational interviewing to promote adherence to antiretroviral medications: a randomized controlled study.

The primary aim of this study was to test an intervention to support antiretroviral medication adherence among primarily low-income men and women with HIV. The study was a randomized controlled trial (Get Busy Living) with participants assigned to treatment (Motivational Interviewing [MI]) and control groups. Participants were recruited from an HIV/AIDS clinic in Atlanta, Georgia, US. Of those referred to the study, 247 completed a baseline assessment and were enrolled with 125 randomized to the intervention group and 122 to the control group. Participants were patients beginning antiretroviral therapy or changing to a new drug regimen. The intervention consisted of five MI sessions delivered by registered nurses in individual counselling sessions. Participants were paid for each session attended. The intervention sought to build confidence, reduce ambivalence and increase motivation for ART medication-taking. Medication adherence was measured by the Medication Event Monitoring System (MEMS) from the time of screening until the final follow-up conducted approximately 12 months following the baseline assessment. Participants in the intervention condition showed a trend towards having a higher mean percent of prescribed doses taken and a greater percent of doses taken on schedule when compared to the control group during the months following the intervention period. This effect was noted beginning at about the eighth month of the study period and was maintained until the final study month. Although the finding was weaker for overall percent of prescribed doses taken, the results for the percent of doses taken on schedule suggests that the MI intervention may be a useful approach for addressing specific aspects of medication adherence, such as adherrence to a specified dosing schedule.

Process evaluation of an effective church-based diet intervention: Body & Soul

Body and Soul has demonstrated effectiveness as a dietary intervention among African American church members. The process evaluation assessed relationships between program exposure and implementation factors and study outcomes and characterized factors important for adoption, implementation, and maintenance. Data sources included participant surveys and qualitative interviews with program staff, church liaisons, and volunteer advisors who conducted motivational interviewing (MI) calls. Outcomes included changes in dietary intake and psychosocial variables. Process variables included program exposure, participation, and dose and perceptions about MI calls. Results showed that attendance at project events, receiving educational materials, and self-reported quality of the MI calls were associated with significantly (p < .05) greater fruit and vegetable intake, decreased fat consumption, and other secondary outcomes. Interviews indicated implementation and sustainability issues and needs including more training to enhance MI implementation as well as ongoing support and resources. The results have implications for future dissemination efforts of Body and Soul. (AU)

A randomized trial of targeted educational materials for smoking cessation in African Americans using transdermal nicotine

This study examines the efficacy of targeted versus standard care smoking cessation materials among urban African American smokers. Five hundred smokers (250 to each group) are randomized to receive a culturally targeted or standard care videotape and print guide. Both groups receive 8 weeks of nicotine patches and reminder telephone calls at Weeks 1 and 3. Process outcomes include material use and salience at 1 and 4 weeks postbaseline. Smoking outcomes include 7-day abstinence, smoking reduction, and readiness to quit at 4 weeks and 6 months postbaseline. Despite greater use of the targeted guide (68.8 per cent vs. 59.6 per cent, p < .05), intervention participants do not perceive the targeted materials as more salient, and no significant differences are found between groups on the smoking outcomes. Findings point to the importance of greater audience segmentation and individual tailoring to better match intervention materials to the needs of the priority population. (AU)

Presence of diabetes risk factors in a large U.S. eighth-grade cohort.

OBJECTIVE: The study was conducted in 12 middle schools to determine the prevalence of diabetes, pre-diabetes, and diabetes risk factors in eighth-grade students who were predominantly minority and evaluate the feasibility of collecting physical and laboratory data in schools. RESEARCH DESIGN AND METHODS: Anthropometric measurements and fasting and 2-h post-glucose load blood draws were obtained from approximately 1,740 eighth-grade students. RESULTS: Mean recruitment rate was 50% per school, 49% had BMI > or = 85th percentile, 40.5% had fasting glucose > or = 100 mg/dl, 0.4% had fasting glucose > or = 126 mg/dl, and 2.0% had 2-h glucose > or = 140 mg/dl and 0.1% > or = 200 mg/dl. Mean fasting insulin value was 30.1 microU/ml, 36.2% had fasting insulin > or = 30 microU/ml, and 2-h mean insulin was 102.1 microU/ml. Fasting and 2-h glucose and insulin values increased across BMI percentiles, and fasting glucose was highest in Hispanic and Native American students. CONCLUSIONS: There was a high prevalence of risk factors for diabetes, including impaired fasting glucose (> or =100 mg/dl), hyperinsulinism suggestive of insulin resistance (fasting insulin > or = 30 microU/ml), and BMI > or = 85th percentile. These data suggest that middle schools are appropriate targets for population-based efforts to decrease overweight and diabetes risk.

Dietary pattern as a predictor of change in BMI z-score among girls.

OBJECTIVES: To describe child and adolescent dietary patterns and to determine associations between childhood dietary pattern and longitudinal change in body mass index (BMI) z-score among girls. POPULATION AND METHODS: Healthy girls (n = 101) aged 8-12 years at baseline and 11-19 years at follow-up participated in a longitudinal study of growth and development. Participants kept 7-day dietary records at two points in time. We incorporated time of day, frequency, and amount of energy consumed (defined as percentage of total energy consumed per dietary event) when characterizing dietary patterns. RESULTS: Girls ate an average of 4-5 times per day and consumed most energy in the afternoon and in the evening/night, rather than in the morning. After controlling for baseline BMI, the mean percentage of daily energy consumed in the evening/night was positively associated with change in BMI z-score (P = 0.039). Eating between 4.0 and 5.9 times per day overall and no more than 1.9 times in the evening/night daily were negatively associated with change in BMI z-score (P = 0.002 and 0.047, respectively), after controlling for baseline BMI z-score. DISCUSSION: Recommendations to decrease the percentage of energy coming from the evening/night meal and the number of dietary events to no more than six times per day and two times in the evening/night should be evaluated in future longitudinal investigations.

Food purchased away from home as a predictor of change in BMI z-score among girls.

OBJECTIVES: To assess the relationship between eating food purchased away from home (FAH) and longitudinal change in body mass index (BMI) z-score among girls, and to assess the longitudinal tracking of eating FAH from childhood through adolescence. DESIGN: Participants kept 7-day dietary records at two points in time. The records included the place and time for all foods consumed. We recorded how often participants ate FAH, calculated the percent of total energy derived from FAH, and classified foods as quick-service food, coffee-shop food, or restaurant food. PARTICIPANTS: Healthy girls (n=101) between the ages of 8 and 12 y at baseline and 11 and 19 y at follow-up participated in a longitudinal study of growth and development at the Massachusetts Institute of Technology. STATISTICAL ANALYSES: Analysis of variance was used to assess the relationship between change in BMI z-score and both the frequency of eating FAH and energy derived from eating FAH. The participants' baseline BMI z-score was a significant covariate and was controlled for in both models. We used the kappa coefficient to assess FAH tracking from childhood through adolescence. RESULTS: The frequency of eating quick-service food at baseline was positively associated with change in BMI z-score (F=6.49, P<0.01). Participants who ate quick-service food twice a week or more at baseline had the greatest mean increase in BMI z-score compared to those who ate quick-service food once a week or not at all. Quick-service food eating tracked slightly from childhood through adolescence (k=0.17, P<0.05). DISCUSSION: Adolescent girls who eat quick-service food twice a week or more are likely to increase their relative BMI over time.

A motivational interviewing intervention to increase fruit and vegetable intake through Black churches: results of the Eat for Life trial.

OBJECTIVES: This study reports on Eat for Life, a multicomponent intervention to increase fruit and vegetable consumption among African Americans that was delivered through Black churches. METHODS: Fourteen churches were randomly assigned to 3 treatment conditions: (1) comparison, (2) self-help intervention with 1 telephone cue call, and (3) self-help with 1 cue call and 3 counseling calls. The telephone counseling in group 3 was based on motivational interviewing. The primary outcome, assessed at baseline and 1-year follow-up, was fruit and vegetable intake as assessed by 3 food frequency questionnaires. RESULTS: Change in fruit and vegetable intake was significantly greater in the motivational interviewing group than in the comparison and self-help groups. The net difference between the motivational interviewing and comparison groups was 1.38, 1.03, and 1.21 servings of fruits and vegetables per day for the 2-item, 7-item, and 36-item food frequency questionnaires, respectively. The net difference between the motivational interviewing and self-help groups was 1.14, 1.10, and 0.97 servings for the 2-item, 7-item, and 36-item food frequency questionnaires, respectively. CONCLUSIONS: Motivational interviewing appears to be a promising strategy for modifying dietary behavior, and Black churches are an excellent setting to implement and evaluate health promotion programs.

Obesity intervention among African-American children and adolescents.

Often, researchers and clinicians approach the African-American community from a deficit model with African Americans viewed as having less desirable health practices and higher disease risk; however, in developing interventions for African Americans, it is important to keep in mind positive aspects of black culture as they relate to obesity. For example, the cultural acceptance of a larger body type and less negative views toward overweight individuals need not be viewed as problematic or abnormal. In fact, it could be argued that majority culture has a dysfunctional view of body image and obesity. The fact that whites are less likely to be overweight than African Americans may stem from a value system that places undue emphasis on thinness, youth, and external beauty and a culture that imbues women with shame about how they look and what they eat. Thus, rather than holding whites and majority culture as the ideal, it may be important to incorporate the positive elements of black culture regarding body image and food rather than attempting to shift their values toward those of European Americans. How best to achieve a reduction in obesity and its medical consequences, without inducing undesirable shifts in body image and attitudes toward food, is a formidable but important challenge.

Risk factor distribution among sociodemographically diverse African American adults.

Because African Americans tend to have lower socioeconomic status (SES) than whites and numerous health indicators are related to SES variables, it is important when examining between-group differences in health indices to account for SES differences. This study examined the effects of income and education on several biologic and behavioral risk factors in a sample of sociodemographically diverse African American adults. Approximately 1,000 African American adults (aged 18-87) were recruited from 14 churches with predominantly black membership to participate in a nutrition education intervention. Demographics, height, weight, blood pressure, self-reported cigarette and alcohol use, self-reported diet by food frequency questionnaire, serum carotenoids, serum total cholesterol, and nutrition knowledge were assessed. The association of these risk factors were examined by four levels of education and income. For men, body mass index, blood pressure, total cholesterol, daily intake of fruits and vegetables, serum carotenoids, heavy alcohol use, or exercise were not associated significantly with income or education using analysis of variance (ANOVA). Past month alcohol use and nutrition knowledge were associated positively with education, but not income. For women, body mass index and smoking were associated inversely with income, but not with education. Blood pressure, total cholesterol, intake of fruits and vegetables, heavy alcohol use, and exercise were not associated with either income or education using ANOVA. Serum carotenoids, any 30-day alcohol use, and nutrition knowledge were associated positively with both income and education. Results using linear regression generally were similar for men and women, although a few more variables were associated significantly with SES compared to ANOVA analyses. Several health indicators that have been associated with socioeconomic variables in whites were not associated or only weakly associated in this diverse sample of African Americans. One interpretation of these findings is that SES factors may function differently among blacks and whites.

Differences among African American light, moderate, and heavy smokers.

This study examined differences in demography, behavior, attitude, and physician intervention among African American light, moderate, and heavy smokers. Data were derived from an intervention study designed to assess whether a smoking status stamp would increase screening for smoking status and cessation counseling by physicians. Current analysis included 879 African American smokers categorized into three groups: light (<10 cigarettes/day), moderate (10-19 cigarettes/day), or heavy (> or =20 cigarettes/day) smokers based on number of cigarettes per day smoked. Light smokers constituted 40% of study sample, 33% were moderate smokers, and 27% were heavy smokers. Light smokers were more likely to be female (p<0.001) and have a shorter smoking history (p<0.001). Light smokers were not different in age (p=0.334), or the number of previous quit attempts (p=0.551). Although light smokers were more likely than moderate and heavy smokers to be preparing to quit (p<0.001), they were less likely to be asked their smoking status (p=0.031) or told to arrange follow-up for smoking cessation (p=0.034) by their physicians. Many African American smokers are light smokers. Light smokers are more likely to be female and have a shorter smoking history. Despite their readiness to quit, compared to heavier smokers, African American light smokers are asked about smoking less often by their physicians. Programs are needed to enhance physician intervention in this understudied population of smokers.

Evaluation of the American Cancer Society's Research Promotion Guide.

The American Cancer Society has supported cancer research for more than 50 years and has devoted more than $2.2 billion to cancer research. This article describes an evaluation of the Research Promotion Guide of the American Cancer Society, a reference tool developed by the National Home Office for regional division staff and volunteers whose work involved public relations and fundraising. The purposes of this study were the following: 1) to determine the level and type of use of the guide; and 2) to assess factors that may influence the level and type of use. Fifty-five participants were interviewed by telephone. Overall, 78% of them were aware of the guide. Three factors significantly and positively associated with level of use were: compatibility (the perception that the guide is relevant to one's job); attending a training session; and years employed at the American Cancer Society. This study, a pilot project for the Collaborative Evaluation Fellows Project (CEFP), demonstrated that collaboration between nonprofit and academic institutions is feasible and can serve the needs of the students and organizations. The lessons learned can be applied to evaluations in general and to future CEFP projects.

Conducting health interventions in black churches: a model for building effective partnerships.

This article offers a brief review of recent health promotion and disease prevention programs conducted in Black churches and identifies benefits and limitations of conducting interventions in these settings. In addition, a review of three current studies being conducted by our group at the Emory University Rollins School of Public Health provides a discussion of a successful model for forming and maintaining effective partnerships between Black churches and public health organizations.

Validation of three food frequency questionnaires and 24-hour recalls with serum carotenoid levels in a sample of African-American adults.

The validity of self-reported fruit and vegetable intake in minority populations has not been adequately established. In this study, the authors examined the association of three food frequency questionnaires (FFQs) and 24-hour dietary recalls with serum carotenoid levels. Approximately 1,000 African-American adults recruited from 15 churches in Atlanta, Georgia (1997-1998) completed three fruit and vegetable FFQs: a seven-item instrument assessing intake during the past month; a two-item measure assessing usual intake; and a 36-item measure adapted from the Health Habits and History Questionnaire. A total of 414 participants received a 24-hour recall by telephone, and 105 of them received two additional recalls. Serum levels of lycopene, lutein, cryptoxanthin, alpha-carotene, and beta-carotene were assessed in 813 participants and used as the validity criterion. The correlations of fruit and vegetable servings with specific and total serum carotenoid levels were generally higher for the 36-item FFQ than for the two-item and seven-item instruments. The strongest correlation of fruit and vegetable servings with total carotenoid levels was observed for the three recalls (r = 0.42), with the 36-item FFQ and the single 24-hour recall yielding comparable correlations (r = 0.35 and r = 0.37, respectively). The validity of the 36-item fruit and vegetable FFQ was generally as strong as the validity of both 1 and 3 days of recalls. Given the lower cost and time needed for administration relative to recalls, it appears that the 36-item FFQ has merit for evaluating fruit and vegetable health interventions.

Development of a modified picture-sort food frequency questionnaire administered to low-income, overweight, African-American adolescent girls.

There is essentially no ideal method of dietary assessment. Physiologic methods (i.e., doubly labeled water) probably come closest, but high cost, participant burden, and limited information limit their use. Furthermore, most dietary assessment methods have been designed for and tested in white adults. Very few have been designed for and tested in African-American adolescents. This study examined validity and reliability of a modified picture-sort food frequency questionnaire (FFQ) administered to 22 low-income, overweight, African-American adolescent girls, aged 11 to 17 years. The FFQ was administered to subjects twice during a 2-week period, and evaluated using the mean values of three 24-hour recalls. The natural log-transformed energy-adjusted, deattenuated correlation coefficients between the second FFQ and the mean from 3 recalls exceeded 0.50 for most nutrients, ranging from 0.32 (protein) to 0.87 (saturated fat). The energy and nutrient values from the first FFQ were greater than those from the second FFQ. Most correlation coefficients for the test-retest reliability of the FFQ were not significant. We conclude that although larger samples are needed to generalize results, the picture-sort dietary assessment method appears to be promising and merits further research.